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Ghadiyaram A, Krishnakumar A, Leppo J, Rajagopal MM, Poulos NT, Opalak CF, Broaddus WC, Cameron BM. A4 Thoracolumbar Fracture Class Is Associated With a Greater Degree of Vertebral Height Loss in Conservatively Managed Patients. Cureus 2024; 16:e66402. [PMID: 39247015 PMCID: PMC11379500 DOI: 10.7759/cureus.66402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2024] [Indexed: 09/10/2024] Open
Abstract
INTRODUCTION Thoracolumbar (TL) junction fractures are common, often resulting from high-energy trauma or osteoporosis, and may lead to neurological deficits, deformities, or chronic pain. Treatment decisions for neurologically intact patients remain controversial, with nonsurgical management often favored. The AO classification system has been used to characterize thoracolumbar fractures using fracture morphology and clinical factors affecting clinical decision-making for fracture management. This study aims to assess the radiographic outcomes of utilizing a thoracolumbosacral orthosis (TLSO) brace in neurologically intact patients with TL fractures based on the AO classification system. METHODS A retrospective analysis of 43 patients was conducted using data from the VCU Spine Database on patients with TL fractures managed conservatively with a TLSO brace from 2010 to 2019. Demographic variables and radiographic measurements of anterior height loss were analyzed and stratified by AO fracture class. RESULTS Significant differences were observed in anterior height loss between AO fracture classes, with A4 fractures showing significantly greater anterior height loss at initial presentation (27.6 + 4.8%) compared to A1/A2 (16.1 + 2.2%; p=0.049). At follow up, A4 fractures had a significantly greater anterior height loss (40.2 + 6.6%) than both the A1/A2 (22.4 + 2.9%; p=0.029) and A3 fracture classes (20.5 + 3.6; p=0.020). CONCLUSIONS The study highlights significant differences in anterior height loss among AO fracture classes, suggesting varying degrees of severity and potential implications for clinical management. While conservative treatment with TLSO braces may provide pain relief, surgical intervention may offer better structural recovery, especially in more severe fractures. Conservative management of TL fractures with TLSO braces may result in greater anterior height loss, particularly in A4 fractures, emphasizing the need for individualized treatment decisions. Further research, including prospective studies, is warranted to validate these findings and guide clinical practice effectively.
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Affiliation(s)
- Ashwin Ghadiyaram
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
| | - Asha Krishnakumar
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
| | - Janan Leppo
- Department of Internal Medicine, University of California San Diego, San Diego, USA
| | - Megan M Rajagopal
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
| | - Nora T Poulos
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
| | - Charles F Opalak
- Neurosurgery, Prisma Health Southeastern Neurosurgical and Spine Institute, Greenville, USA
| | - William C Broaddus
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
| | - Brian M Cameron
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, USA
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Azizi A, Azizzadeh A, Tavakoli Y, Vahed N, Mousavi T. Thoracolumbar fracture and spinal cord injury in blunt trauma: a systematic review, meta-analysis, and meta-regression. Neurosurg Rev 2024; 47:333. [PMID: 39009953 DOI: 10.1007/s10143-024-02553-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/20/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024]
Abstract
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.
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Affiliation(s)
- Ali Azizi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Yasaman Tavakoli
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Nafiseh Vahed
- Research Center for Evidence Based Medicine, Iranian EBM Centre: A JBI Centre of Excellence, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Taher Mousavi
- Department of Neurosurgery, Tabriz University of Medical Sciences, Golgasht Avenue, Tabriz, Iran.
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Zhu Z, Chen G, Ma T, Wang S, Tang X, Liu C. A Novel Leverage Technique Using Monoaxial Pedicle Screw for Reduction of Thoracolumbar Compression Fractures: Surgical Technique and Analysis of Radiological Parameters. Orthop Surg 2024; 16:1538-1547. [PMID: 38784977 PMCID: PMC11216827 DOI: 10.1111/os.14065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVE Thoracolumbar compression fractures resulting from high-energy injuries are a common type of spinal fracture. Satisfying reduction of compressive vertebra body is essential for the clinical outcome. However, traditional distraction technique may lead to complications including pedicle screw loosening, pedicle screw breakage, and postoperative back pain because of excessive distraction. In this study, we reported a novel technique for reduction. Additionally, the effect and postoperative radiological parameters of this technique were compared with those of traditional distraction technique. METHODS The clinical data of 80 patients who had been treated with posterior pedicle screw fixation from January 2019 to December 2020 was retrospectively analyzed. Thirty-six patients were performed with the leverage technique, while 22 patients were treated with the traditional distraction technique. When pedicle screw fixation was performed with either the leverage technique or the traditional distraction technique, fracture reduction was completed with monoaxial pedicle screws using either the leverage maneuver or distraction of adjacent vertebrae. Clinical evaluation, including operation time, hospital stay, blood loss volume, and postoperative complications were collected. The American Spinal Injury Association (ASIA) score for neurological condition and the visual analog scale (VAS) score for pain were used to evaluate the patients' functional outcome. The radiographic analysis included local kyphotic angle (LKA), regional kyphotic angle (RKA), anterior vertebral height (AVH), posterior vertebral height (PVH), and sagittal compression (SC). The student t-test and the χ2-test (or the Fisher exact test) were used to compare the outcome measures between the two groups. RESULTS The leverage group comprised 36 patients, while 44 patients were included in the distraction group. No statistically significant differences were found in the demographic data. The VAS score in the leverage group (3.0 ± 0.8) was significantly lower than that in the distraction group (4.2 ± 0.6) on postoperative day 1. Total correction of the LKA in the leverage group (11.5 ± 2.5°) was significantly higher than that in the distraction group (7.1 ± 1.3°) (p = 0.0004). Total correction of the RKA was higher in the leverage group (12.1 ± 4.3°) than in the distraction group (6.1 ± 0.9°) (p = 0.005). The ratio of rear pillar /front pillar correction was 0.35 ± 0.13 and 0.89 ± 0.18 in the leverage and distraction groups, respectively (p = 0.014). Total correction of the upper and lower foraminal height in the leverage group was significantly less than that in the distraction group. The leverage group had significantly higher correction of the upper and lower intervertebral space height than the distraction group. CONCLUSIONS Our novel leverage technique provided better kyphotic reduction and restoration than compared to conventional distraction technique in the surgical treatment of thoracolumbar compression fractures.
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Affiliation(s)
- Ziqing Zhu
- Department of Orthopedics, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Guangzi Chen
- Department of Orthopedics, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Tian Ma
- Department of Orthopedics, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Shanxi Wang
- Department of Orthopedics, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xiangyu Tang
- Department of Radiology, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Chaoxu Liu
- Department of Orthopedics, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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Rieger LK, Shah A, Schick S, Draper DB, Cutlan R, Peldschus S, Stemper BD. Subject-Specific Geometry of FE Lumbar Spine Models for the Replication of Fracture Locations Using Dynamic Drop Tests. Ann Biomed Eng 2024; 52:816-831. [PMID: 38374520 DOI: 10.1007/s10439-023-03402-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/28/2023] [Indexed: 02/21/2024]
Abstract
For traumatic lumbar spine injuries, the mechanisms and influence of anthropometrical variation are not yet fully understood under dynamic loading. Our objective was to evaluate whether geometrically subject-specific explicit finite element (FE) lumbar spine models based on state-of-the-art clinical CT data combined with general material properties from the literature could replicate the experimental responses and the fracture locations via a dynamic drop tower-test setup. The experimental CT datasets from a dynamic drop tower-test setup were used to create anatomical details of four lumbar spine models (T12 to L5). The soft tissues from THUMS v4.1 were integrated by morphing. Each model was simulated with the corresponding loading and boundary conditions from the dynamic lumbar spine tests that produced differing injuries and injury locations. The simulations resulted in force, moment, and kinematic responses that effectively matched the experimental data. The pressure distribution within the models was used to compare the fracture occurrence and location. The spinal levels that sustained vertebral body fracture in the experiment showed higher simulation pressure values in the anterior elements than those in the levels that did not fracture in the reference experiments. Similarly, the spinal levels that sustained posterior element fracture in the experiments showed higher simulation pressure values in the vertebral posterior structures compared to those in the levels that did not sustain fracture. Our study showed that the incorporation of the spinal geometry and orientation could be used to replicate the fracture type and location under dynamic loading. Our results provided an understanding of the lumbar injury mechanisms and knowledge on the load thresholds that could be used for injury prediction with explicit FE lumbar spine models.
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Affiliation(s)
- Laura K Rieger
- Biomechanics and Accident Analysis, Ludwig-Maximilians-Universität (LMU), Munich, Germany.
- Occupant Protection System & Virtual Function Development, Volkswagen AG, Letter Box 011/1606, 38436, Wolfsburg, Germany.
| | - Alok Shah
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, USA
- Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
| | - Sylvia Schick
- Biomechanics and Accident Analysis, Ludwig-Maximilians-Universität (LMU), Munich, Germany
| | - Dustin B Draper
- Biomechanics and Accident Analysis, Ludwig-Maximilians-Universität (LMU), Munich, Germany
| | - Rachel Cutlan
- Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Steffen Peldschus
- Biomechanics and Accident Analysis, Ludwig-Maximilians-Universität (LMU), Munich, Germany
| | - Brian D Stemper
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, USA
- Neuroscience Research, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
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Williams CM, Henschke N, Maher CG, van Tulder MW, Koes BW, Macaskill P, Irwig L. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev 2023; 11:CD008643. [PMID: 38014846 PMCID: PMC10683370 DOI: 10.1002/14651858.cd008643.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
EDITORIAL NOTE See https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD014461.pub2/full for a more recent review that covers this topic and has superseded this review. BACKGROUND Low-back pain (LBP) is a common condition seen in primary care. A principal aim during a clinical examination is to identify patients with a higher likelihood of underlying serious pathology, such as vertebral fracture, who may require additional investigation and specific treatment. All 'evidence-based' clinical practice guidelines recommend the use of red flags to screen for serious causes of back pain. However, it remains unclear if the diagnostic accuracy of red flags is sufficient to support this recommendation. OBJECTIVES To assess the diagnostic accuracy of red flags obtained in a clinical history or physical examination to screen for vertebral fracture in patients presenting with LBP. SEARCH METHODS Electronic databases were searched for primary studies between the earliest date and 7 March 2012. Forward and backward citation searching of eligible studies was also conducted. SELECTION CRITERIA Studies were considered if they compared the results of any aspect of the history or test conducted in the physical examination of patients presenting for LBP or examination of the lumbar spine, with a reference standard (diagnostic imaging). The selection criteria were independently applied by two review authors. DATA COLLECTION AND ANALYSIS Three review authors independently conducted 'Risk of bias' assessment and data extraction. Risk of bias was assessed using the 11-item QUADAS tool. Characteristics of studies, patients, index tests and reference standards were extracted. Where available, raw data were used to calculate sensitivity and specificity with 95% confidence intervals (CI). Due to the heterogeneity of studies and tests, statistical pooling was not appropriate and the analysis for the review was descriptive only. Likelihood ratios for each test were calculated and used as an indication of clinical usefulness. MAIN RESULTS Eight studies set in primary (four), secondary (one) and tertiary care (accident and emergency = three) were included in the review. Overall, the risk of bias of studies was moderate with high risk of selection and verification bias the predominant flaws. Reporting of index and reference tests was poor. The prevalence of vertebral fracture in accident and emergency settings ranged from 6.5% to 11% and in primary care from 0.7% to 4.5%. There were 29 groups of index tests investigated however, only two featured in more than two studies. Descriptive analyses revealed that three red flags in primary care were potentially useful with meaningful positive likelihood ratios (LR+) but mostly imprecise estimates (significant trauma, older age, corticosteroid use; LR+ point estimate ranging 3.42 to 12.85, 3.69 to 9.39, 3.97 to 48.50 respectively). One red flag in tertiary care appeared informative (contusion/abrasion; LR+ 31.09, 95% CI 18.25 to 52.96). The results of combined tests appeared more informative than individual red flags with LR+ estimates generally greater in magnitude and precision. AUTHORS' CONCLUSIONS The available evidence does not support the use of many red flags to specifically screen for vertebral fracture in patients presenting for LBP. Based on evidence from single studies, few individual red flags appear informative as most have poor diagnostic accuracy as indicated by imprecise estimates of likelihood ratios. When combinations of red flags were used the performance appeared to improve. From the limited evidence, the findings give rise to a weak recommendation that a combination of a small subset of red flags may be useful to screen for vertebral fracture. It should also be noted that many red flags have high false positive rates; and if acted upon uncritically there would be consequences for the cost of management and outcomes of patients with LBP. Further research should focus on appropriate sets of red flags and adequate reporting of both index and reference tests.
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Affiliation(s)
| | | | | | - Maurits W van Tulder
- MOVE Research Institute Amsterdam, Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Bart W Koes
- Center for Muscle and Health, University of Southern Denmark, Odense, Denmark
| | - Petra Macaskill
- Screening and Test Evaluation Program (STEP), School of Public Health, Sydney, Australia
| | - Les Irwig
- School of Public Health, University of Sydney, Sydney, Australia
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Hax J, Teuben M, Halvachizadeh S, Berk T, Scherer J, Jensen KO, Lefering R, Pape HC, Sprengel K. Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries. Global Spine J 2023:21925682231216082. [PMID: 37963389 DOI: 10.1177/21925682231216082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
STUDY DESIGN Retrospective database analysis. OBJECTIVE Polytraumatized patients with spinal injuries require tailor-made treatment plans. Severity of both spinal and concomitant injuries determine timing of spinal surgery. Aim of this study was to evaluate the role of spinal injury localization, severity and concurrent injury patterns on timing of surgery and subsequent outcome. METHODS The TraumaRegister DGU® was utilized and patients, aged ≥16 years, with an Injury Severity Score (ISS) ≥16 and diagnosed with relevant spinal injuries (abbreviated injury scale, AIS ≥ 3) were selected. Concurrent spinal and non-spinal injuries were analysed and the relation between injury severity, concurrent injury patterns and timing of spinal surgery was determined. RESULTS 12.596 patients with a mean age of 50.8 years were included. 7.2% of patients had relevant multisegmental spinal injuries. Furthermore, 50% of patients with spine injuries AIS ≥3 had a more severe non-spinal injury to another body part. ICU and hospital stay were superior in patients treated within 48 hrs for lumbar and thoracic spinal injuries. In cervical injuries early intervention (<48 hrs) was associated with increased mortality rates (9.7 vs 6.3%). CONCLUSIONS The current multicentre study demonstrates that polytrauma patients frequently sustain multiple spinal injuries, and those with an index spine injury may therefore benefit from standardized whole-spine imaging. Moreover, timing of surgical spinal surgery and outcome appear to depend on the severity of concomitant injuries and spinal injury localization. Future prospective studies are needed to identify trauma characteristics that are associated with improved outcome upon early or late spinal surgery.
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Affiliation(s)
- Jakob Hax
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Department of Hip and Knee Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | | | - Till Berk
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Julian Scherer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Orthopaedic Research Unit, University of Cape Town, Cape Town, South Africa
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Department of Trauma, Hirslanden Clinic St. Anna and University of Lucerne, Lucerne, Switzerland
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Felton J, John AA, Daneshfar SC, Cox CT, Grochmal J. Novel Nerve-Sparing In Situ Assembly of an Expandable Titanium Cage to Maximize Endplate Coverage After Posterior Corpectomy for Comminuted Lumbar Burst Fractures. Oper Neurosurg (Hagerstown) 2023; 25:386-393. [PMID: 37499255 PMCID: PMC10578748 DOI: 10.1227/ons.0000000000000827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/11/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The ability to maximize corpectomy cage endcap size and vertebral endplate coverage after corpectomy for lumbar burst fractures (L1-L5) is limited by the presence of lumbar nerve roots and the larger cross-sectional area of the lumbar endplates relative to the restrictive corridor for cage insertion. This work aims to provide details and clinical examples of a novel operative technique for 3-column reconstruction and stabilization of comminuted lumbar burst fractures. METHODS Through a standard posterior midline approach and following posterior instrumentation and lateral extracavitary corpectomy, an in-situ assembly of a modular corpectomy cage that respects adjacent neural structures, restores segmental alignment, and maximizes endplate coverage across a lordotic segment is completed. RESULTS Radiographic evidence of anatomic spinal reconstruction and stabilization with complete or near-complete endplate coverage without incurrence of new clinical deficit after this novel treatment of lumbar burst fractures. CONCLUSION The fixation approach described in this report may be a valuable modification to a long-standing technique used for treating comminuted lumbar burst fractures (L1-L5) from a posterior-only approach without incurring additional neurological deficits and by improving endplate and apophyseal ring coverage.
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Affiliation(s)
- Jason Felton
- Division of Neurosurgery, University Medical Center Physicians, Lubbock, Texas, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Albin A. John
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Shahriar C. Daneshfar
- Department of Orthopedic Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Cameron T. Cox
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Joey Grochmal
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Chen Q, Maher CG. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database Syst Rev 2023; 8:CD014461. [PMID: 37615643 PMCID: PMC10448864 DOI: 10.1002/14651858.cd014461.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture. OBJECTIVES To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture). SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022. SELECTION CRITERIA We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool. MAIN RESULTS This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96). AUTHORS' CONCLUSIONS The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.
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Affiliation(s)
- Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Mark J Hancock
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Aron Downie
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Jeffrey G Jarvik
- Departments of Radiology and Neurological Surgery, and the UW Clinical Learning, Evidence And Research (CLEAR) Center for Musculoskeletal Disorders, University of Washington School of Medicine, Seattle, USA
| | - Bart W Koes
- Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Department of General Practice, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Arianne P Verhagen
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney (UTS), Sydney, Australia
| | | | - Qiuzhe Chen
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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Heilig P, Heilig M, Fuchs KF, Hoelscher-Doht S, Meffert RH, Heintel T. Retroperitoneal arterial bleeding caused by an undisplaced conservatively treated hyperextension injury of the lumbar spine - A case report. Trauma Case Rep 2023; 46:100854. [PMID: 37304217 PMCID: PMC10248247 DOI: 10.1016/j.tcr.2023.100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 06/13/2023] Open
Abstract
Background Hyperextension fractures of the thoracolumbar spine are commonly seen in ankylotic disorders due to the rigidity of the spine. The known complications include instability, neurological deficits and posttraumatic deformity but there is no report of a hemodynamic relevant arterial bleeding in undisplaced hyperextension fractures. An arterial bleeding poses a life-threatening complication and may be difficult to recognize in an ambulatory or clinical setting. Case presentation A 78-year-old male was brought to the emergency department after suffering a domestic fall with incapacitating lower back pain. X-rays and a CT scan revealed an undisplaced L2 hyperextension fracture which was treated conservatively. 9 days after admission, the patient complained about unprecedented abdominal pain with a CT scan disclosing a 12 × 9 × 20 cm retroperitoneal hematoma on grounds of an active arterial bleeding from a branch of the L2 lumbar artery. Subsequently, access via lumbotomy, evacuation of the hematoma and insertion of a hemostatic agent was performed. The therapy concept of the L2 fracture remained conservatively. Conclusions A secondary, retroperitoneal arterial bleeding after a conservatively treated undisplaced hyperextension fracture of the lumbar spine is a rare and severe complication that has not been described in literature yet and may be difficult to recognize. An early CT scan is recommended in case of a sudden onset of abdominal pain in these fractures to fasten treatment and hence decrease morbidity and mortality. Thus, this case report contributes to the awareness of this complication in a spine fracture type with increasing incidence and clinical relevance.
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10
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Mathieu J, Pasquier M, Descarreaux M, Marchand AA. Diagnosis Value of Patient Evaluation Components Applicable in Primary Care Settings for the Diagnosis of Low Back Pain: A Scoping Review of Systematic Reviews. J Clin Med 2023; 12:jcm12103581. [PMID: 37240687 DOI: 10.3390/jcm12103581] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/16/2023] [Accepted: 05/20/2023] [Indexed: 05/28/2023] Open
Abstract
Low back pain ranks as the leading cause of years lived with disability worldwide. Although best practice guidelines share a consistent diagnostic approach for the evaluation of patients with low back pain, confusion remains as to what extent patient history and physical examination findings can inform management strategies. The aim of this study was to summarize evidence investigating the diagnostic value of patient evaluation components applicable in primary care settings for the diagnosis of low back pain. To this end, peer-reviewed systematic reviews were searched in MEDLINE, CINAHL, PsycINFO and Cochrane databases from 1 January 2000 to 10 April 2023. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data. Of the 2077 articles identified, 27 met the inclusion criteria, focusing on the diagnosis of lumbar spinal stenosis, radicular syndrome, non- specific low back pain and specific low back pain. Most patient evaluation components lack diagnostic accuracy for the diagnosis of low back pain when considered in isolation. Further research is needed to develop evidence-based and standardized evaluation procedures, especially for primary care settings where evidence is still scarce.
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Affiliation(s)
- Janny Mathieu
- Department of Anatomy, Université du Québec à Trois-Rivières, 3351, Boul. des Forges, C.P. 500, Trois-Rivieres, QC G8Z 4M3, Canada
| | - Mégane Pasquier
- Institut Franco-Européen de Chiropraxie, 72 Chemin de la Flambère, 31300 Toulouse, France
| | - Martin Descarreaux
- Department of Human Kinetics, Université du Québec à Trois-Rivières, 3351, Boul. des Forges, C.P. 500, Trois-Rivières, QC G8Z 4M3, Canada
| | - Andrée-Anne Marchand
- Department of Chiropractic, Université du Québec à Trois-Rivières, 3351, Boul. des Forges, C.P. 500, Trois-Rivières, QC G8Z 4M3, Canada
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11
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Henriques M, Saliba-Serre B, Martrille L, Blum A, Chaumoître K, Donato P, Campos N, Cunha E, Adalian P. Discrimination between falls and blows from the localization and the number of fractures on computed tomography scans of the skull and the trunk. Forensic Sci Res 2023; 8:30-40. [PMID: 37415795 PMCID: PMC10265964 DOI: 10.1093/fsr/owad006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/27/2022] [Indexed: 11/04/2023] Open
Abstract
The distinction between falls and blows is a common and difficult task in forensic sciences. One of the most often used criteria to address this issue is the hat brim line (HBL) rule, which states that fall-related injuries do not lie above the HBL. Some studies, however, have found that the use of HBL rule is not so relevant. This study assesses the aetiologies, the number of fractures, and their location on the skull and the trunk in a sample of 400 individuals aged 20-49 years, which were CT scanned after traumas. This may facilitate the interpretation of such injuries in skeletonized or heavily decomposed bodies in which soft tissues are no longer available. Our aim is to improve the distinction rate between falls and blows by combining several criteria and assessing their predictability. Skeletal lesions were analysed using retrospective CT scans. Cases selected comprise 235 falls and 165 blows. We registered the presence and the number of fractures in 14 skeletal anatomical regions related to the two different aetiologies. We showed that the HBL rule should be used with caution, but there is nevertheless a possibility of discussing the aetiology of blunt fractures. Possibly, parameters like the anatomical location and the number of fractures by region can be used to distinguish falls and blows.
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Affiliation(s)
- Mélanie Henriques
- Centre for Functional Ecology (CEF), Laboratory of Forensic Anthropology, Department of Life Sciences, University of Coimbra, Coimbra, Portugal
- Aix Marseille University, CNRS, EFS, ADES, Marseille, France
| | | | | | - Alain Blum
- Guilloz Imaging Department, Central Hospital, University Hospital of Nancy (CHRU-Nancy), Nancy, France
| | - Kathia Chaumoître
- Department of Radiology and Medical Imaging, CHU Nord, Assistance Publique – Hôpitaux de Marseille, Marseille Cedex, France
| | - Paulo Donato
- Department of Radiology, University Centre Hospitals of Coimbra (CHUC), Coimbra, Portugal
| | - Nuno Campos
- Department of Radiology, University Centre Hospitals of Coimbra (CHUC), Coimbra, Portugal
| | - Eugénia Cunha
- Centre for Functional Ecology (CEF), Laboratory of Forensic Anthropology, Department of Life Sciences, University of Coimbra, Coimbra, Portugal
- National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal
| | - Pascal Adalian
- Aix Marseille University, CNRS, EFS, ADES, Marseille, France
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12
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Henriques M, Bonhomme V, Cunha E, Adalian P. Blows or Falls? Distinction by Random Forest Classification. BIOLOGY 2023; 12:206. [PMID: 36829485 PMCID: PMC9952774 DOI: 10.3390/biology12020206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/10/2023] [Accepted: 01/26/2023] [Indexed: 02/03/2023]
Abstract
In this study, we propose a classification method between falls and blows using random forests. In total, 400 anonymized patients presenting with fractures from falls or blows aged between 20 and 49 years old were used. There were 549 types of fractures for 57 bones and 12 anatomical regions observed. We first tested various models according to the sensibility of random forest parameters and their effects on model accuracies. The best model was based on the binary coding of 12 anatomical regions or 28 bones with or without baseline (age and sex). Our method achieved the highest accuracy rate of 83% in the distinction between falls and blows. Our findings pave the way for applications to help forensic experts and archaeologists.
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Affiliation(s)
- Mélanie Henriques
- Centre for Functional Ecology (CEF), Laboratory of Forensic Anthropology, Department of Life Sciences, University of Coimbra, 3000-456 Coimbra, Portugal
- Aix Marseille Univ, CNRS, EFS, ADES, 13007 Marseille, France
| | | | - Eugénia Cunha
- Centre for Functional Ecology (CEF), Laboratory of Forensic Anthropology, Department of Life Sciences, University of Coimbra, 3000-456 Coimbra, Portugal
- National Institute of Legal Medicine and Forensic Sciences, 3000-456 Coimbra, Portugal
| | - Pascal Adalian
- Aix Marseille Univ, CNRS, EFS, ADES, 13007 Marseille, France
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13
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Takaoka H, Eguchi Y, Shibahashi K, Ozone E, Teramura S, Takeda T, Kitagawa K, Sai K, Setojima Y, Masaki Y, Mizutani M, Hamabe Y, Sugiyama K, Orita S, Inage K, Shiga Y, Shiko Y, Kawasaki Y, Ohtori S. Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:68-74. [PMID: 36469132 DOI: 10.1007/s00586-022-07478-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/17/2022] [Accepted: 11/22/2022] [Indexed: 12/09/2022]
Abstract
PURPOSE Thoracolumbar spine injury is frequently seen with high-energy trauma but dislocation fractures are relatively rare in spinal trauma, which is often neurologically severe and requires urgent treatment. Therefore, it is essential to understand other concomitant injuries when treating dislocation fractures. The purpose of this study is to determine the differences in clinical features between thoracolumbar spine injury without dislocation and thoracolumbar dislocation fracture. METHODS We conducted an observational study using the Japan Trauma Data Bank (2004-2019). A total of 734 dislocation fractures (Type C) and 32,382 thoracolumbar spine injuries without dislocation (Non-type C) were included in the study. The patient background, injury mechanism, and major complications in both groups were compared. In addition, multivariate analysis of predictors of the diagnosis of dislocation fracture using logistic regression analysis were performed. RESULTS Items significantly more frequent in Type C than in Non-type C were males, hypotension, bradycardia, percentage of complete paralysis, falling objects, pincer pressure, accidents during sports, and thoracic artery injury (P < 0.001); items significantly more frequent in Non-type C than in Type C were falls and traffic accidents, head injury, and pelvic trauma (P < 0.001). Logistic regression analysis showed that younger age, male, complete paralysis, bradycardia, and hypotension were associated with dislocation fracture. CONCLUSION Five associated factors were identified in the development of thoracolumbar dislocation fractures. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hiromitsu Takaoka
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan.
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba, Japan
| | - Keita Shibahashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Ei Ozone
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Shin Teramura
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Takuto Takeda
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Kyota Kitagawa
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Koichi Sai
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Yusuke Setojima
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Yuta Masaki
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Masaya Mizutani
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Yuichi Hamabe
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Kazuhiro Sugiyama
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba, Japan.,Center for Frontier Medical Engineering, Chiba University, Chiba, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba, Japan
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14
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Yin N, Du L, Pan M, Xue F, Shen Y, Ding L. Minimally invasive technique of monoaxial percutaneous screws and instrumentational maneuvers in thoracolumbar and lumbar fractures. Injury 2022; 53:4028-4032. [PMID: 36184359 DOI: 10.1016/j.injury.2022.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 09/05/2022] [Accepted: 09/16/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Percutaneous pedicle screw fixation (PPSF) has been a common surgery for treating thoracolumbar and lumbar fractures. Many studies have reported PPSF is associated with poor reduction. We present a reliable method by using short-segment monoaxial percutaneous screws and instrumentational maneuvers to reduce the spine. This study aimed to evaluate radiological and clinical results of this method of reduction compared to traditional polyaxial screws method in treating thoracolumbar and lumbar fractures. METHODS From February 2015 to February 2021, 64 patients with thoracolumbar and lumbar fractures in our department were retrospectively reviewed and divided into experimental group and control group according to different treatment methods. The experimental group was treated with short-segment monoaxial percutaneous screws (which were inserted at the adjacent vertebrae one level above, one level below the fracture, and the fractured vertebra) and instrumentational maneuvers method, while the control group was treated with traditional polyaxial screws method. The operation time was recorded. Visual analogue scale (VAS) and Oswestry disability index (ODI) were assessed as the clinical outcomes. The anterior height of the injured vertebra (AVH), the kyphosis cobb angle and the vertebral wedge angle were used to evaluate the fracture radiological reduction. RESULTS A total of 64 patients were enrolled including 31 in the experimental group and 33 in the control group. There were no significant difference in operation time, AVH, the kyphosis cobb angle,the wedge angle of injured vertebra,VAS and ODI score between the two groups in preoperation. In each group, there were significant differences in the AVH, the kyphosis cobb angle and wedge angle of injured vertebra between preoperation and immediate postoperation. In each group, there were significant differences in VAS and ODI score between the preoperation and last follow-up. The total correction rates of AVH,the kyphosis cobb angle and the wedge angle of injured vertebra were significantly higher in the experimental group than those in the control group, while the loss of correction was significantly lower than the control. CONCLUSIONS The reduction technique using monoaxial percutaneous screws and instrumentational maneuvers for thoracolumbar and lumbar fractures exhibited better radiological results and satisfying functional outcomes when compared to traditional polyaxial screws.
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Affiliation(s)
- Nuo Yin
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital. 6600 Nanfeng Road, Fengxian District, Shanghai, 201499, China
| | - Li Du
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital. 6600 Nanfeng Road, Fengxian District, Shanghai, 201499, China
| | - Mingmang Pan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital. 6600 Nanfeng Road, Fengxian District, Shanghai, 201499, China
| | - Feng Xue
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital. 6600 Nanfeng Road, Fengxian District, Shanghai, 201499, China
| | - Yuchun Shen
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital. 6600 Nanfeng Road, Fengxian District, Shanghai, 201499, China
| | - Liang Ding
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital. 6600 Nanfeng Road, Fengxian District, Shanghai, 201499, China.
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15
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Safdari M, Safdari Z, Pishjoo M, Seifirad S, Kheradmand D, Saghebdoust S. Radiological outcome of operative treatment with posterior approach in patients with thoracolumbar junction traumatic injuries: A single-center pilot study in a developing country. Surg Neurol Int 2022; 13:376. [PMID: 36128110 PMCID: PMC9479520 DOI: 10.25259/sni_46_2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background: The thoracolumbar junction (TLJ) represents a transition zone of the spine that leads to a high incidence of fractures. The treatment of burst fractures remains controversial regarding the ideal management. This study assessed the postoperative radiological outcome of TLJ fixation in patients with TLJ injuries who underwent surgery. Methods: All traumatic patients with TLJ injuries who were referred to the Khatam hospital of Zahedan between 2015 and 2020, with their thoracolumbar injury classification and severity score (TLICS) of four or more and who underwent surgery, were included in this study. The patients who entered the study were called for a follow-up examination. The degree of kyphosis, proximal junctional kyphosis, and fusion were assessed in these patients. Results: Among 273 patients, the average age was 43.5 ± 12.3 (21–73) years. One hundred and ninety-eight patients (72.5%) had no neurological symptoms at admission. Based on the above criteria, the kyphosis angle of these patients was calculated before surgery, which in 46 patients (16.8%), the kyphosis angle was more than 25°. Preoperation kyphosis was significantly associated with follow-up kyphosis (P < 0.001). Evidence of no fusion was also observed in 22 patients (8.1%). According to the Chi-square test, no association was observed between preoperative kyphosis and postoperative complications, including PJK and fusion (P > 0.05). Conclusion: According to our study, the posterior spinal fixation procedure is a low-complication method with an acceptable radiological outcome. Although kyphosis before surgery is a factor in developing long-term kyphosis, it is not associated with nonfusion and PJK.
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Affiliation(s)
- Mohammad Safdari
- Department of Neurosurgery, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Zohre Safdari
- Department of Radiology, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Masoud Pishjoo
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sirous Seifirad
- Department of Radiology, Faculty of Medicine, Islamic Azad University, Mashhad, Iran
| | - Daniel Kheradmand
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
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16
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Peng Z, Cui Z, Kuang X, Yu C, Ruan Y, Li C, Li S, Lu S. Intervertebral disc injury is the mainspring for the postoperative increase in Cobb Angle after thoracolumbar burst fracture. J Orthop Surg (Hong Kong) 2022; 30:10225536221088753. [PMID: 35507450 DOI: 10.1177/10225536221088753] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN A single-institution retrospective study of a cohort of patients who underwent internal fixation spine surgery for thoracolumbar burst fracture (TLBF). OBJECTIVE To observe the imaging manifestations of intervertebral disc changes in TLBF, to analyze the relationship between the degree of disc injury and the Cobb angle increase. METHODS We retrospectively analyzed the data of patients who underwent short-segment pedicle screw instrumentation in the spinal surgery department of a single hospital between January 2014 and December 2017 (n = 90). According to the magnetic resonance imaging characteristics of the superior intervertebral disc tissue of the injured vertebrae before the operation, the intervertebral disc injury was divided into three types, which was used for group allocation: group A, uninjured intervertebral disc group; group B, mild intervertebral disc injury group; and group C, severe intervertebral disc injury group. The main imaging results of the three groups Cobb, IVA, IHI, AHIV, and VAS were compared among groups. RESULTS Ninety patients were included in the study (n = 38, 32, and 20, in groups A, B, and C, respectively). There was no statistically significant difference in demographics among the three groups (p > .05). 1-year post-surgery, the Cobb angle in group C differed significantly from that in groups A and B (p < .01). There was a significant difference in Cobb angle between groups A and B after internal fixation was removed for 6 months. At 1-year post-surgery, the IHI group C differed significantly from groups A and B (p < .01), while groups A and B were similar (p = .102); however, at 6 months after the internal fixation was removed, the IHI differed significantly between these two groups, also the AHIV between groups A and B was statistically significant (p < .01). The VAS pain score was similar among the three groups. Pearson's test showed that the increase in the Cobb angle was moderately correlated with IVA and IHI, and weakly correlated with AHIV. CONCLUSION For TLBF with an intervertebral disc injury, the presurgical degree of intervertebral disc injury is the main reason for the post-surgery increase in the Cobb angle. Thus, diagnosis and treatment of this kind of patient require attention to the risk of spinal deformity.
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Affiliation(s)
- Zhi Peng
- Department of Orthopedic Surgery, the First People's Hospital of Yunnan Province, the Affiliated Hospital of Kunming University of Science and Technology, 71240Key Laboratory of Digital Orthopaedics of Yunnan Province, Kunming, China.,Graduate School of Kunming Medical University, 746211168, Chunrongxi Road, Kunming, Yunnan, China
| | - Zhongfeng Cui
- Department of Emergency, 577528The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaolin Kuang
- The 1st Department of Hepatic Diseases, 71240People's Hospital of Kunming City, 319 Wujing Road, Kunming, China
| | - Chen Yu
- Department of Orthopedic Surgery, the First People's Hospital of Yunnan Province, the Affiliated Hospital of Kunming University of Science and Technology, 71240Key Laboratory of Digital Orthopaedics of Yunnan Province, Kunming, China
| | - Yushan Ruan
- Department of Spinal Surgery, The 1st Affiliated Hospital of Dali University, Dali, China
| | - Chuan Li
- Graduate School of Kunming Medical University, 746211168, Chunrongxi Road, Kunming, Yunnan, China
| | - Shaobo Li
- Department of Spinal Surgery, The 1st Affiliated Hospital of Dali University, Dali, China
| | - Sheng Lu
- Department of Orthopedic Surgery, the First People's Hospital of Yunnan Province, the Affiliated Hospital of Kunming University of Science and Technology, 71240Key Laboratory of Digital Orthopaedics of Yunnan Province, Kunming, China
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17
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Habermehl N, Minich NM, Malay S, Mahran A, Kim G. Pediatric Thoracolumbar Spinal Injuries in United States Trauma Centers. Pediatr Emerg Care 2022; 38:e876-e880. [PMID: 33848099 DOI: 10.1097/pec.0000000000002427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Injuries are the leading cause of morbidity and mortality in children ages 1 to 18 years. There are limited studies about pediatric thoracolumbar (TL) spinal injuries; the purpose of this study was to characterize TL spinal injuries among pediatric patients evaluated in US trauma centers. METHODS This was a retrospective cohort study of the National Trauma Data Bank. Patients aged 1 to 18 years with a thoracic or lumbar spinal injury sustained by blunt trauma during calendar years 2011 through 2016 were included. Cervical spinal injuries, death before arrival, or penetrating trauma were excluded. The data was abstracted, and missing data was addressed by imputations. Data was analyzed using descriptive statistics and multinomial logistic regressions. RESULTS A total of 20,062 patients were included in the study. Thoracolumbar spinal injuries were more commonly sustained by 16- to 17-year-olds (45.7%), boys (56.6%), and White (74.8%). The injuries were often from a motor vehicle collision (MVC) (55.2%) and resulted in a bone injury (82.3%). Mechanism of injury and age were significant in predicting injury type. A fall was more likely than MVC to result in disc injury (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.24-2.33), strain injury (OR, 1.18; 95% CI, 1.05-1.34), or cord injury (OR, 1.27; 95% CI, 1.12-1.45). Younger children were more likely than adolescents to present with disc injury (OR, 2.79; 95% CI, 1.75-4.45), cord injury (OR, 1.46; 95% CI, 1.18-1.81), or strain injury (OR, 1.37; 95% CI, 1.09-1.72). CONCLUSIONS To our knowledge, this is the largest pediatric TL spinal study. Clinicians should consider TL spinal injuries when adolescents present after an MVC, and specifically, TL spinal cord injuries when young children present after a fall. Additionally, pediatric TL spinal injury prevention should highlight motor vehicle and fall safety.
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Affiliation(s)
- Nikita Habermehl
- From the Division of Pediatric Emergency Medicine, Rainbow Babies & Children's Hospital
| | - Nori Mercuri Minich
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sindhoosha Malay
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Amr Mahran
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
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18
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Spine trauma: Radiological approach and new concepts. Skeletal Radiol 2021; 50:1065-1079. [PMID: 33165712 DOI: 10.1007/s00256-020-03668-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/30/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
The spine is the main stabilizer and load bearer of the axial skeleton. It is also important for the protection of neural structures, such as the spinal cord, nerve roots, and cauda equina. In the healthy skeleton, most injuries are a consequence of high-energy trauma and can lead to severe dysfunction, such as tetraplegia or paraplegia. In order to avoid such disabilities, it is important to recognize details that will guide treatment, and that will determine the necessity or not to have surgery. Familiarity with radiography, CT, and MRI in evaluating spine trauma is necessary, as, in some cases, all three methods will be useful in determining management and surgical planning. The most important factor in determining management in the thoracolumbar spine is the posterior ligamentous complex (PLC). Therefore, familiarity with its anatomy, primary and secondary signs of its injuries, is essential for radiologists in the emergency setting. Spine fractures are a very heterogeneous group of disorders. Management can be both conservative and surgical. It is important for radiologists to be aware of classifications and patterns for these injuries.
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Ruddell JH, DePasse JM, Tang OY, Daniels AH. Timing of Surgery for Thoracolumbar Spine Trauma: Patients With Neurological Injury. Clin Spine Surg 2021; 34:E229-E236. [PMID: 33027090 DOI: 10.1097/bsd.0000000000001078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Large multicenter retrospective cohort study. OBJECTIVE The objective of this study was to analyze the effect of fusion timing on inpatient outcomes in a nationally representative population with thoracolumbar fracture and concurrent neurological injury. SUMMARY OF BACKGROUND DATA Among thoracolumbar trauma admissions, concurrent neurological injury is associated with greater long-term morbidity. There is little consensus on optimal surgical timing for these patients; previous investigations fail to differentiate thoracolumbar fracture with and without neurological injury. MATERIALS AND METHODS We analyzed 19,136 nonelective National Inpatient Sample cases (2004-2014) containing International Classifications of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for closed thoracic/lumbar fracture with neurological injury and procedure codes for primary thoracolumbar/lumbosacral fusion, excluding open/cervical fracture. Timing classification from admission to fusion was same-day, 1-2-, 3-6-, and ≥7-day delay. Primary outcomes included in-hospital mortality, complications, and infection; secondary outcomes included total and postoperative length of stay and charges. Logistic regressions and generalized linear models with gamma distribution and log-link evaluated the effect of surgical timing on primary and secondary outcomes, respectively, controlling for age, sex, fracture location, fusion approach, multiorgan system injury severity score, and medical comorbidities. RESULTS Patients undergoing surgery ≤72 hours (n=12,845) had the lowest odds of in-hospital cardiac [odds ratio (OR)=0.595; 95% confidence interval (CI), 0.357-0.991] and respiratory complications (OR=0.495; 95% CI, 0.313-0.784) and infection (OR=0.615; 95% CI, 0.390-0.969). No differences were observed between same-day (n=4724) and 1-2-day delay (n=8121) (P>0.05). Lowest odds of hemorrhage or hematoma was observed following 3-6-day delay (OR=0.467; 95% CI, 0.236-0.922). A ≥7-day delay to fusion (n=2,002) was associated with greatest odds of hemorrhage/hematoma (OR=2.019; 1.107-3.683), respiratory complications (OR=1.850; 95% CI, 1.076-3.180), and infection (OR=3.155; 95% CI, 1.891-5.263) and greatest increases in mean postoperative length of stay (4.26% or 35.3% additional days) and charges (163,562 or 71.7% additional US dollars) (P<0.001). CONCLUSIONS Patients with thoracolumbar fracture and associated neurological injury who underwent surgery within 3 days of admission experienced fewer in-hospital complications. These benefits may be due to secondary injury mechanism avoidance and earlier mobilization. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - J Mason DePasse
- Division of Spine, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | | | - Alan H Daniels
- Division of Spine, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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Hax J, Halvachizadeh S, Jensen KO, Berk T, Teuber H, Di Primio T, Lefering R, Pape HC, Sprengel K. Curiosity or Underdiagnosed? Injuries to Thoracolumbar Spine with Concomitant Trauma to Pancreas. J Clin Med 2021; 10:jcm10040700. [PMID: 33670128 PMCID: PMC7916827 DOI: 10.3390/jcm10040700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 12/26/2022] Open
Abstract
The pancreas is at risk of damage as a consequence of thoracolumbar spine injury. However, there are no studies providing prevalence data to support this assumption. Data from European hospitals documented in the TraumaRegister DGU® (TR-DGU) between 2008–2017 were analyzed to estimate the prevalence of this correlation and to determine the impact on clinical outcome. A total of 44,279 patients with significant thoracolumbar trauma, defined on Abbreviated Injury Scale (AIS) as ≥2, were included. Patients transferred to another hospital within 48 h were excluded to prevent double counting. A total of 135,567 patients without thoracolumbar injuries (AIS ≤ 1) were used as control group. Four-hundred patients with thoracolumbar trauma had a pancreatic injury. Pancreatic injuries were more common after thoracolumbar trauma (0.90% versus (vs.) 0.51%, odds ratio (OR) 1.78; 95% confidence intervals (CI), 1.57–2.01). Patients with pancreatic injuries were more likely to be male (68%) and had a higher mean Injury Severity Score (ISS) than those without (35.7 ± 16.0 vs. 23.8 ± 12.4). Mean length of stay (LOS) in intensive care unit (ICU) and hospital was longer with pancreatic injury. In-hospital mortality was 17.5% with and 9.7% without pancreatic injury, respectively. Although uncommon, concurrent pancreatic injury in the setting of thoracolumbar trauma can portend a much more serious injury.
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Affiliation(s)
- Jakob Hax
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (K.O.J.); (T.B.); (H.T.); (T.D.P.); (H.-C.P.); (K.S.)
- Correspondence: ; Tel.: +41-76-722-4180
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (K.O.J.); (T.B.); (H.T.); (T.D.P.); (H.-C.P.); (K.S.)
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (K.O.J.); (T.B.); (H.T.); (T.D.P.); (H.-C.P.); (K.S.)
| | - Till Berk
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (K.O.J.); (T.B.); (H.T.); (T.D.P.); (H.-C.P.); (K.S.)
| | - Henrik Teuber
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (K.O.J.); (T.B.); (H.T.); (T.D.P.); (H.-C.P.); (K.S.)
| | - Teresa Di Primio
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (K.O.J.); (T.B.); (H.T.); (T.D.P.); (H.-C.P.); (K.S.)
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, 51109 Cologne, Germany;
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (K.O.J.); (T.B.); (H.T.); (T.D.P.); (H.-C.P.); (K.S.)
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (K.O.J.); (T.B.); (H.T.); (T.D.P.); (H.-C.P.); (K.S.)
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21
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Yu S, Choi HJ, Lee JH, Kim BC, Ha M, Han IH. Associated Injuries in Spine Trauma Patients: A Single-Center Experience. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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22
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Chang SW, Choi KK, Kim OH, Kim M, Lee GJ. Part 4. Clinical Practice Guideline for Surveillance and Imaging Studies of Trauma Patients in the Trauma Bay from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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23
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Management of thoracolumbar fracture in France. Analysis of practices and radiologic results of a cohort of 407 thoracolumbar fractures. Orthop Traumatol Surg Res 2020; 106:1203-1207. [PMID: 32763012 DOI: 10.1016/j.otsr.2020.02.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 01/12/2020] [Accepted: 02/25/2020] [Indexed: 02/03/2023]
Abstract
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.
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Maselli F, Palladino M, Barbari V, Storari L, Rossettini G, Testa M. The diagnostic value of Red Flags in thoracolumbar pain: a systematic review. Disabil Rehabil 2020; 44:1190-1206. [PMID: 32813559 DOI: 10.1080/09638288.2020.1804626] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE Red Flags (RFs) are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal pain. The current literature wonders about the usefulness of RFs, due to high false-positive rates and low diagnostic accuracy. The aims of this systematic review are: (a) to identify and (b) to evaluate the most important RFs that could be found by a health care professional during the assessment of patients with low and upper back pain (named as thoracolumbar pain (TLP)) to screen serious pathologies. MATERIALS AND METHODS A systematic review of the literature was conducted. Searches were performed on seven databases (Pubmed, Web of Science, Cochrane Library, Pedro, Scielo, CINAHL, and Google Scholar) between March 2019 and June 2020, using a search string which included synonyms of low back pain (LBP), chest pain (CP), differential diagnosis, RF, and serious disease. Only observational studies enrolling patients with LBP or CP were included. Risk of bias was assessed with the Newcastle Ottawa Scale and inter-rater agreement between authors for full-text selection was evaluated with Cohen's Kappa. Where possible the diagnostic accuracy was recorded for sensitivity (Sn), specificity (Sp), and positive/negative likelihood ratio (LR+/LR-). RESULTS Forty full-texts were included. Most of the included observational studies were judged as low risk of bias, and Cohen's Kappa was good (=0.78). The identified RFs were: advanced age; neurological signs; history of trauma; malignancy; female gender; corticosteroids use; night pain; unintentional weight loss; bladder or bowel dysfunction; loss of anal sphincter tone; saddle anaesthesia; constant pain; recent infection; family or personal history of heart or pulmonary diseases; dyspnoea; fever; postprandial CP; typical reflux symptoms; haemoptysis; sweating; pain radiated to upper limbs; hypotension; retrosternal pain; exertional pain; diaphoresis; and tachycardia. The diagnostic accuracy of RFs as self-contained screening tool was low, while the combination of multiple RFs showed to increase the probability to identify serious pathologies. CONCLUSIONS Despite the use of single RF should not be recommended for the screening process in clinical practice, the combination of multiple RFs to enhance diagnostic accuracy is promising. Moreover, the identified RFs could be a baseline to develop a screening tool for patients with TLP.Implications for rehabilitationDifferential diagnosis and screening for referral are mandatory skills for each healthcare professional in direct access clinical settings, and should be the primary step for an appropriate management of a patient with signs and symptoms mimicking serious pathologies in thoracolumbar region.Clinical reasoning and decision-making processes are essential throughout all phases of a patient's pathway of care. By which, the use of single Red Flag (RF) as a self-contained screening tool should not be recommended. The combination of multiple RFs promises to increase diagnostic accuracy and could grow into an excellent screening tool for thoracolumbar pain.
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Affiliation(s)
- Filippo Maselli
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genoa - Campus of Savona, Savona, Italy.,Sovrintendenza Sanitaria Regionale Puglia INAIL, Bari, Italy
| | - Michael Palladino
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genoa - Campus of Savona, Savona, Italy.,Private Practice, Torino, Italy
| | - Valerio Barbari
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genoa - Campus of Savona, Savona, Italy.,Private Practice, Rimini, Italy
| | - Lorenzo Storari
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genoa - Campus of Savona, Savona, Italy.,Private Practice, "Centro Retrain", Verona, Italy
| | - Giacomo Rossettini
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genoa - Campus of Savona, Savona, Italy.,School of Physiotherapy, University of Verona, Verona, Italy
| | - Marco Testa
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genoa - Campus of Savona, Savona, Italy
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25
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Thoracic vertebrae fracture: Is it an indicator of abdominal injury? Am J Emerg Med 2020; 43:235-237. [PMID: 32204979 DOI: 10.1016/j.ajem.2020.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/08/2020] [Accepted: 03/09/2020] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Traumatic vertebral fracture accounts for 10-15% of trauma related admissions. While the correlation between lumbar vertebral fractures and abdominal injuries is well established, the relationship between thoracic vertebral fractures (TVF) and abdominal injuries is comparatively less well elucidated. Using a large national trauma database, we aimed to examine the incidence and severity of associated abdominal injuries in blunt trauma patients suffering from TVF. METHODS A retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic vertebrae spine fractures following blunt mechanisms of trauma between 1997 and 2018 were examined, comparing the incidence and severity of associated intraabdominal organs injuries with and without TVF. Demographics and outcomes between the two cohorts were compared. RESULTS From 362,924 blunt trauma patients, 4967 (1.37%) had isolated TVF. Mean age was 49.8 years and 61.9% were males. The most common mechanism of injury was fall following by MVC. The patients with TVF had significantly higher rates of increased ISS score (ISS > 16, 28.45% vs. 10.42%, p < 0.001) and higher mortality rate (3.5% vs. 2%, p < 0.0001). Patients with TVF had 2-3 times more intraabdominal organ injuries (p < 0.001). The most commonly injured organ was spleen (3.28%); followed by liver (2.64%) and kidney (1.47%). An analysis of non-isolated thoracic spine fractures showed same distribution in age, ISS, mechanisms, patterns of intra-abdominal injury, mortality rate and laparotomy rate. CONCLUSION Clinicians should have an elevated suspicion for intra-abdominal injuries when a thoracic spine fracture is identified, which may necessitate further evaluation.
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26
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Radiological protocol in spinal trauma: literature review and Spinal Cord Society position statement. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:1197-1211. [PMID: 31440893 DOI: 10.1007/s00586-019-06112-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 06/29/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The Spinal Cord Society constituted a panel tasked with reviewing the literature on the radiological evaluation of spinal trauma with or without spinal cord injury and recommend a protocol. This position statement provides recommendations for the use of each modality, i.e., radiographs (X-rays), computed tomography (CT), magnetic resonance imaging (MRI), as well as vascular imaging, and makes suggestions on identifying or clearing spinal injury in trauma patients. METHODS PubMed was searched for the corresponding keywords from January 1, 1980, to August 1, 2017. A MEDLINE search was subsequently undertaken after applying MeSH filters. Appropriate cross-references were retrieved. Out of the 545 articles retrieved, 105 relevant papers that address the present topic were studied and the extracted content was circulated for further discussions. A draft position statement was compiled and circulated among the panel members via e-mail. The draft was modified by incorporating relevant suggestions to reach a consensus. RESULTS AND CONCLUSION For imaging cervical and thoracolumbar spine trauma patients, CT without contrast is generally considered to be the initial line of imaging and radiographs are required if CT is unavailable or unaffordable. CT screening in polytrauma cases is best done with a multidetector CT by utilizing the reformatted images obtained when scanning the chest, abdomen, and pelvis (CT-CAP). MRI is indicated in cases with neurological involvement and advanced cervical degenerative changes and to determine the extent of soft tissue injury, i.e., disco-ligamentous injuries as well as epidural space compromise. MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology. These slides can be retrieved under Electronic Supplementary Material.
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27
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Hercz D, Montrief TD, Kukielski CJ, Supino M. Thoracolumbar Evaluation in the Low-Risk Trauma Patient: A Pilot Study Towards Development of a Clinical Decision Rule to Avoid Unnecessary Imaging in the Emergency Department. J Emerg Med 2019; 57:279-289. [PMID: 31405781 DOI: 10.1016/j.jemermed.2019.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/08/2019] [Accepted: 06/08/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Thoracolumbar (TL) injury is a common finding in the severely injured multi-trauma patient. However, the incidence and pattern of TL injury in patients with milder trauma is unclear. OBJECTIVE The aim of this study was to collect and analyze evidence for the development of a clinical decision rule (CDR) to evaluate the TL spine in patients with non-severe blunt trauma and avoid dedicated imaging in low-risk cases. METHODS Adult patients with blunt trauma who presented to a major academic center (May 2016 to October 2017) and received dedicated imaging of the TL spine were included. Exclusion criteria consisted of any coexisting condition preventing the acquisition of history or examination. The primary endpoint is TL spine injury requiring orthopedic evaluation, bracing/orthosis, or surgery. Preliminary CDR derivation was performed with recursive partitioning. RESULTS Of 4612 patients screened, 1049 (22.7%) met inclusion criteria. Thirty-six (3.4%) patients were found to have TL spine injury, of which 88.9% received spinal bracing, orthosis, or surgery. Absence of midline tenderness conveyed the highest negative predictive value, followed by a non-severe mechanism of injury, lack of neurologic examination findings, and age < 65 years. No patients in this cohort with these four findings had a TL spine injury. CONCLUSIONS In certain lower-risk blunt trauma patients < 65 years of age, focused examination combined with mechanism of injury may be highly sensitive (100%) to rule out TL injury without the need for dedicated imaging. However, validation is necessary, given multiple study limitations. Potential instrument to screen for TL injury in minor trauma: TL injury is unlikely if all four of the following are present: 1) no midline back tenderness or deformity, 2) no focal neurologic signs or symptoms or altered mentation, 3) age < 65 years; and 4) lack of severe mechanism of injury, for example, fall greater than standing, motor-vehicle collision with rollover/ejection/pedestrian or unenclosed vehicle, and assault with a weapon.
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Affiliation(s)
- Daniel Hercz
- Department of Emergency Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Timothy D Montrief
- Department of Emergency Medicine, Jackson Memorial Hospital, Miami, Florida
| | | | - Mark Supino
- Department of Emergency Medicine, Jackson Memorial Hospital, Miami, Florida
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28
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Lee GY, Hwang JY, Kim NR, Kang Y, Choi M, Kim J, Ha EJ, Baek JH. Primary Imaging Test for Suspected Traumatic Thoracolumbar Spine Injury: 2017 Guidelines by the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency. Korean J Radiol 2019; 20:909-915. [PMID: 31132816 PMCID: PMC6536791 DOI: 10.3348/kjr.2018.0792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 12/25/2022] Open
Abstract
The Korean Society of Radiology and the National Evidence-based Healthcare Collaborating Agency developed a primary imaging test for suspected traumatic thoracolumbar spine injury. This guideline was developed using an adaptation process involving collaboration between the development committee and the working group. The development committee, consisting of research methodology experts, established the overall plan and provided support on research methodology. The working group, composed of radiologists with expertise in musculoskeletal imaging, wrote the recommendation. The guidelines recommend that thoracolumbar spine computed tomography without intravenous contrast enhancement be the first-line imaging modality for diagnosing traumatic thoracolumbar spine injury in adults.
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Affiliation(s)
- Guen Young Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Ji Young Hwang
- Department of Radiology, Ewha Womans University Seoul Hospital, Seoul, Korea.
| | - Na Ra Kim
- Department of Radiology, Gunkuk University Hostpial, Seoul, Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jimin Kim
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Eun Ju Ha
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea
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Mitra B, El-Menyar A, Mercier E, Liew S, Varma D, Fitzgerald MC, Al-Hilli S, Peralta R, Al-Thani H, Cameron PA. Clinical clearance of the thoracic and lumbar spine: a pilot study. ANZ J Surg 2019; 89:718-722. [PMID: 31083786 DOI: 10.1111/ans.15253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/21/2019] [Accepted: 03/27/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients who are awake with normal mental and neurologic status, it has been suggested that the thoracolumbar (TL) spine may be cleared by clinical examination, irrespective of the mechanism of injury. The aim of this pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the TL spine during assessment of patients in the emergency department after trauma. METHODS A prospective interventional study was conducted at two major trauma centres. The intervention of a clinical decision tool for assessment of the TL spine was applied prospectively to all patients with subsequent imaging results acting as the comparator. The primary outcome variable was fracture of the thoracic or lumbar vertebra(e). The clinical decision tool was assessed using sensitivity and specificity for detecting a TL fracture and reported with 95% confidence intervals (CIs). RESULTS There were 188 cases included for analysis that all underwent imaging of the thoracic and/or lumbar vertebrae. There were 34 (18%) patients diagnosed with fractures of the thoracic and/or lumbar vertebrae. In this pilot study, sensitivity of the clinical decision tool was 100% (95% CI 87.3-100%) and specificity was 37.0% (95% CI 29.5-45.2%) for the detection of a thoracic or lumbar vertebral fracture. CONCLUSIONS Feasibility of clinical clearance of the TL spine in two major trauma centres was demonstrated in a clinical study setting. Evaluation of this clinical decision tool in patients following blunt trauma, particularly in reducing imaging rates, is indicated using a larger prospective study.
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Affiliation(s)
- Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Ayman El-Menyar
- Department of Surgery, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Eric Mercier
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices, Université Laval, Québec, Canada.,Département de Médecine Familiale et Médecine d'Urgence, Faculté de Médecine, Université Laval, Québec, Canada.,Centre de Recherche Sur Les Soins Et Les Services De Première Ligne De l'Université Laval, Québec, Canada
| | - Susan Liew
- Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Dinesh Varma
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark C Fitzgerald
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Shatha Al-Hilli
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar.,Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Peter A Cameron
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
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Beckmann NM, West OC, Nunez D, Kirsch CF, Aulino JM, Broder JS, Cassidy RC, Czuczman GJ, Demertzis JL, Johnson MM, Motamedi K, Reitman C, Shah LM, Than K, Ying-Kou Yung E, Beaman FD, Kransdorf MJ, Bykowski J. ACR Appropriateness Criteria® Suspected Spine Trauma. J Am Coll Radiol 2019; 16:S264-S285. [DOI: 10.1016/j.jacr.2019.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
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Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging. J Emerg Med 2018; 56:153-165. [PMID: 30598296 DOI: 10.1016/j.jemermed.2018.10.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 10/16/2018] [Accepted: 10/25/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging. OBJECTIVE Our aim was to quantify the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients. METHODS A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2 × 2 tables, were duplicates, were not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios. RESULTS In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1-152.2; I2 = 94%; p < 0.001) and negative likelihood ratio (-LR) = 0.43 (95% CI 0.32-0.59; I2 = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1-467.9; I2 = 87%; p < 0.001) and -LR = 0.04 (95% CI 0.02-0.08; I2 = 23%; p = 0.26). CONCLUSIONS CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.
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Yuen J, Selbi W, Lee L, Germon T. Usefulness of antero-posterior radiograph and variability of management in non-major thoracolumbar injuries: a single centre pilot study and review of literature. Chin Neurosurg J 2018; 4:29. [PMID: 32922890 PMCID: PMC7398401 DOI: 10.1186/s41016-018-0136-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/06/2018] [Indexed: 11/30/2022] Open
Abstract
Background Most adult trauma protocols suggest that where there has been a dangerous mechanism of injury or the patient exhibits abnormal physiology, CT scan is the primary radiological investigation. Other patients who may have suffered thoraco-lumbar (T-L) trauma initially have antero-posterior (AP) and lateral plain X-rays performed. Our clinical experience suggests AP views are not particularly useful in the management of these relatively low-velocity injuries. This is the first study intended to determine the contribution made by AP X-rays in these cases. Methods Adults with a history of T-L trauma referred to our tertiary spinal service over 20 weeks were reviewed. Those with a CT scan performed prior to X-rays were excluded. Four spine surgeons and four neuroradiologists were independently shown lateral X-rays along with the clinical details and asked to provide a management plan. Then they were shown the AP X-rays and asked if they would like to change their advice. Results Fifty-two patients were identified. Thirty-four sets of supine and 40 sets of erect X-rays were included (four people only had lateral X-rays performed), yielding 1152 film views. Average patient age was 58.3 years with 30 (58%) males. Forty-five (87%) were AO type A (compression-type) fractures. Seven (13%) had been erroneously referred with a diagnosis of acute fracture, which on review was not considered to be the case. Fifty-four percent of fractures were between T11 and L2. Forty-six percent appeared osteoporotic. In no instance did evaluation of the AP X-ray change the management plan which had been suggested following the evaluation of the lateral X-ray alone. However, there was significant variation in advice on further management between consultants. Conclusions Our results suggest AP X-rays do not contribute to the management of low-velocity thoraco-lumbar traumas. Larger studies are required to support these findings, but there appears to be a potential to reduce both cost and radiation exposure. More importantly, it demonstrates there is large variability in the management of such patients due to the lack of evidence-based protocols.
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Tian F, Tu LY, Gu WF, Zhang EF, Wang ZB, Chu G, Ka H, Zhao J. Percutaneous versus open pedicle screw instrumentation in treatment of thoracic and lumbar spine fractures: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12535. [PMID: 30313040 PMCID: PMC6203502 DOI: 10.1097/md.0000000000012535] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND To assess the safety and efficacy of percutaneous short-segment pedicle instrumentation compared with conventionally open short-segment pedicle instrumentation and provide recommendations for using these procedures to treat thoracolumbar fractures. METHODS The Medline database, Cochrane database of Systematic Reviews, Cochrane Clinical Trial Register, and Embase were searched for articles published. The randomized controlled trials (RCTs) and non-RCTs that compared percutaneous short-segment pedicle instrumentation to open short-segment pedicle instrumentation and provided data on safety and clinical effects were included. Demographic characteristics, clinical outcomes, radiological outcomes, and adverse events were manually extracted from all of the selected studies. Methodological quality of included studies using Methodological Index for Non-Randomized Studies scale and Cochrane collaboration's tool for assessing the risk of bias by 2 reviewers independently. RESULTS Nine studies encompassing 433 patients met the inclusion criteria. Subgroup meta-analyses were performed according to the study design. The pooled results showed there were significant differences between the 2 techniques in short- and long-term visual analog scale, intraoperative blood loss, operative time, postoperative draining loss, hospital stay, and incision size, although there were no significant differences in postoperative radiological outcomes, Oswestry Disability Index, hospitalization cost, intraoperative fluoroscopy time, and adverse events. CONCLUSION Percutaneous short-segment pedicle instrumentation in cases with achieve satisfactory results, could replace in many cases extensive open surgery and not increased related complications. However, further high-quality RCTs are needed to assess the long-term outcome of patients between 2 techniques.
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Singh R, Taylor DM, D'Souza D, Gorelik A, Page P, Phal P. Mechanism of Injury and Clinical Variables in Thoracic Spine Fracture: A Case Control Study. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791101800102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To determine the mechanisms of injury and clinical findings significantly associated with traumatic thoracic spine (T-spine) fractures. Methods This was a case-control study in a tertiary adult trauma centre. Cases were patients admitted with traumatic T-spine fractures between January 1999 and August 2007, inclusive. Each case had two controls matched for gender, age and injury severity. Data were collected from patient medical records and the trauma service database. Factors potentially associated with T-spine fracture were derived from the literature, expert consensus and univariate analysis. Multivariate logistic regression was employed to determine factors significantly associated with T-spine fracture. Results Two hundred and sixty one cases and 512 controls were enrolled. Univariate analysis showed the mechanisms of fall from a height ≥2 meters (m) and motorbike accident ≥60 kilometers per hour were significantly associated with T-spine fracture (p<0.001). The clinical findings of thoracic back pain, tenderness, intoxication, step deformity and abnormal neurological symptoms were also significantly associated with T-spine fracture (p<0.05). Multivariate analysis indicated that falls from a height of ≥2 m and thoracic back pain were significantly and positively associated with T-spine fracture (p<0.001). However, intoxication was negatively associated with T-spine fracture. Conclusions Patients with T-spine injury are significantly more likely to have fallen from a height ≥2 m or to have had thoracic back pain but less likely to be intoxicated. These findings should be validated prospectively prior to development of clinical guidelines for the identification of patients who may benefit from CT screening of the thoracic spine.
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Affiliation(s)
- R Singh
- University of Melbourne, Faculty of Medicine, Parkville, Melbourne, Victoria, Australia 3010
| | | | - D D'Souza
- Toronto General Hospital, Toronto, Canada
| | - A Gorelik
- Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia 3050
| | - P Page
- Box Hill, Box Hill Radiology, Victoria, Australia 3128
| | - P Phal
- Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia 3050
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Tins BJ. Imaging investigations in Spine Trauma: The value of commonly used imaging modalities and emerging imaging modalities. J Clin Orthop Trauma 2017; 8:107-115. [PMID: 28720986 PMCID: PMC5498756 DOI: 10.1016/j.jcot.2017.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/03/2017] [Indexed: 10/19/2022] Open
Abstract
Traumatic spine injuries can be devastating for patients affected and for health care professionals if preventable neurological deterioration occurs. This review discusses the imaging options for the diagnosis of spinal trauma. It lays out when imaging is appropriate and when it is not. It discusses strength and weakness of available imaging modalities. Advanced techniques for spinal injury imaging will be explored. The review concludes with a review of imaging protocols adjusted to clinical circumstances.
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Riddell J, Inaba K, Jhun P, Herbert M. A Clinical Decision Rule for Thoracolumbar Spine Imaging in Blunt Trauma? Ann Emerg Med 2016; 68:781-783. [DOI: 10.1016/j.annemergmed.2016.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Minimally Invasive Posterior Decompression Combined With Percutaneous Pedicle Screw Fixation for the Treatment of Thoracolumbar Fractures With Neurological Deficits: A Prospective Randomized Study Versus Traditional Open Posterior Surgery. Spine (Phila Pa 1976) 2016; 41 Suppl 19:B23-B29. [PMID: 27656782 DOI: 10.1097/brs.0000000000001814] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective randomized cohort study. OBJECTIVE To compare the surgical results of minimally invasive posterior decompression combined with percutaneous pedicle screws fixation (minimally invasive surgery [MIS]) and posterior open surgery (OS) for the treatment of thoracolumbar fracture with neurological deficits. SUMMARY OF BACKGROUND DATA Thoracolumbar fracture with neurological deficits usually undergoes surgical intervention. OS can achieve satisfied results, but the main disadvantage is approach-related complications. No study, however, focused on the treatment of this disease by MIS through posterior approach. METHODS Sixty consecutive cases of thoracolumbar fractures with neurological deficits were randomized into MIS group and OS group. Incision length, blood loss, postoperative drainage volume, hospitalization days, blood transfusion rate, analgesic use rate, and x-ray exposure time were used to evaluate the perioperative information and Visual Analog Scale (VAS), Japanese Orthopedics Association (JOA) score, and American Spinal Injury Association grade for patients' symptom. For radiological assessment, sagittal Cobb angle, percentage of vertebral height, and vertebral wedging angle were measured. RESULTS Fifty-nine of sixty patients were followed-up for at least 12 months. MIS group was superior in perioperative information (P < 0.05), except in the operative time (P = 0.165) and x-ray time (P = 0.000). The operative time seemed longer in MIS group, but no significant difference was found. The x-ray time was significantly higher in MIS group. The mean Visual Analog Scale and Japanese Orthopedics Association scores of the final follow-up in MIS group were better than that in OS group (P < 0.05). Patients in both group achieved a similar neurological recovery according to American Spinal Injury Association grade (P = 0.760). A broken screw was found in one patient in MIS group and a broken rod in one patient in OS group. CONCLUSION MIS group has achieved the similar effect of OS group and it can minimize the approach-related complication. It also faced with some shortages, such as larger radiation dose and longer learning curve. LEVEL OF EVIDENCE 2.
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Rozenberg A, Weinstein JC, Flanders AE, Sharma P. Imaging of the thoracic and lumbar spine in a high volume level 1 trauma center: are reformatted images of the spine essential for screening in blunt trauma? Emerg Radiol 2016; 24:55-59. [DOI: 10.1007/s10140-016-1445-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 09/15/2016] [Indexed: 11/25/2022]
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Beal AL, Ahrendt MN, Irwin ED, Lyng JW, Turner SV, Beal CA, Byrnes MT, Beilman GA. Prediction of blunt traumatic injuries and hospital admission based on history and physical exam. World J Emerg Surg 2016; 11:46. [PMID: 27588036 PMCID: PMC5007839 DOI: 10.1186/s13017-016-0099-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 08/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We evaluated the ability of experienced trauma surgeons to accurately predict specific blunt injuries, as well as patient disposition from the emergency department (ED), based only on the initial clinical evaluation and prior to any imaging studies. It would be hypothesized that experienced trauma surgeons' initial clinical evaluation is accurate for excluding life-threatening blunt injuries and for appropriate admission triage decisions. METHODS Using only their history and physical exam, and prior to any imaging studies, three (3) experienced trauma surgeons, with a combined Level 1 trauma experience of over 50 years, predicted injuries in patients with an initial GCS (Glasgow Coma Score) of 14-15. Additionally, ED disposition (ICU, floor, discharge to home) was also predicted. These predictions were compared to actual patient dispositions and to blunt injuries documented at discharge. RESULTS A total of 101 patients with 92 blunt injuries were studied. 43/92 (46.7 %) injuries would have been missed by only performing an initial history and physical exam ("Missed injury"). A change in treatment, though often minor, was required in 19/43 (44.2 %) of the missed injuries. Only 1/43 (2.3 %) of these "missed injuries" (blunt aortic injury) required surgery. Sensitivity, specificity, and accuracy for injury prediction were 53.2, 95.9, and 92.3 % respectively. Positive and negative predictive values were 53.8 and 95.8 % respectively. Prediction of disposition from the ED was 77.8 % accurate. In 7/34 (20.6 %) patients, missed injuries led to changes in disposition. "Undertriage" occurred in 9/99 (9.1 %) patients (Predicted for floor but admitted to ICU). Additionally, 8/84 (9.5 %) patients predicted for floor admission were sent home from the ED; and 5/13 (38.5 %) patients predicted for ICU admission were actually sent to the floor after complete evaluations, giving an "overtriage" rate of 13/99 (13.1 %) patients. CONCLUSIONS In a neurologically-intact group of trauma patients, experienced trauma surgeons would have missed 46.7 % of the actual injuries, based only on their history and physical exam. Once accurate diagnoses of injuries were completed, usually with the help of CT scans, admission dispositions changed in 20.6 % of patients. Treatment changes occurred in 44.2 % of the missed injuries, though usually minimal. Broad elimination of early imaging studies in alert, blunt trauma patients cannot be advocated.
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Affiliation(s)
- Alan L Beal
- North Memorial Medical Center, 3300 Oakdale Ave N, Robbinsdale, MN 55431 USA
| | | | | | - John W Lyng
- North Memorial Medical Center, Minnesota, USA
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Katsuura Y, Osborn JM, Cason GW. The epidemiology of thoracolumbar trauma: A meta-analysis. J Orthop 2016; 13:383-8. [PMID: 27504058 DOI: 10.1016/j.jor.2016.06.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 06/24/2016] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To describe the epidemiology of thoracolumbar fractures and associated injuries in blunt trauma patients. METHODS A systematic review and metaanalysis was performed based on a MEDLINE database search using MeSH terms for studies matching our inclusion criteria. The search yielded 21 full-length articles, each sub-grouped according to content. Data extraction and multiple analyses were performed on descriptive data. RESULTS The rate of thoracolumbar fracture in blunt trauma patients was 6.90% (±3.77, 95% CI). The rate of spinal cord injury was 26.56% (±10.70), and non-contiguous cervical spine fracture occurred in 10.49% (±4.17). Associated injury was as follows: abdominal trauma 7.63% (±9.74), thoracic trauma 22.64% (±13.94), pelvic trauma 9.39% (±6.45), extremity trauma 18.26% (±5.95), and head trauma 12.96% (±2.01). Studies that included cervical spine fracture with thoracolumbar fracture had the following rates of associated trauma: 3.78% (±5.94) abdominal trauma, 21.65% (±16.79) thoracic trauma, 3.62% (±1.07) pelvic trauma, 18.36% (±4.94) extremity trauma, and 15.45% (±11.70) head trauma. A subgroup of flexion distraction injuries showed an associated intra-abdominal injury rate of 38.70% (±13.30). The most common vertebra injured was L1 at a rate of 34.40% (±15.90). T7 was the most common non-junctional vertebra injured at 3.90% (±1.09). Burst/AO type A3 fractures were the most common morphology 39.50% (±16.30) followed by 33.60% (±15.10) compression/AO type A1, 14.20% (±8.08) fracture dislocation/AO type C, and 6.96% (±3.50) flexion distraction/AO type B. The most common etiology for a thoracolumbar fracture was motor vehicle collision 36.70% (±5.35), followed by high-energy fall 31.70% (±6.70). CONCLUSIONS Here we report the incidence of thoracolumbar fracture in blunt trauma and the spectrum of associated injuries. To our knowledge, this paper provides the first epidemiological road map for blunt trauma thoracolumbar injuries.
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Affiliation(s)
- Yoshihiro Katsuura
- University of Tennessee College of Medicine Chattanooga, Department of Orthopaedic Surgery, 975 East Third Street, Box 260, Chattanooga, TN 37403, USA
| | - James Michael Osborn
- University of Tennessee College of Medicine Chattanooga, Department of Orthopaedic Surgery, 975 East Third Street, Box 260, Chattanooga, TN 37403, USA
| | - Garrick Wayne Cason
- University of Tennessee College of Medicine Chattanooga, Department of Orthopaedic Surgery, 975 East Third Street, Box 260, Chattanooga, TN 37403, USA
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Cahueque M, Cobar A, Zuñiga C, Caldera G. Management of burst fractures in the thoracolumbar spine. J Orthop 2016; 13:278-81. [PMID: 27408503 DOI: 10.1016/j.jor.2016.06.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/07/2016] [Indexed: 12/14/2022] Open
Abstract
UNLABELLED The most common fractures in the spine take place in the thoracolumbar region. Currently there is no consensus regarding optimum treatment. OBJECTIVE Analyze the current medical literature available regarding treatment of compression fractures of the thoracolumbar spine. METHODS Research of current literature in medical databases. RESULTS Regarding current available literature, we found no consensus in the treatment of compression fractures in the thoracolumbar spine. CONCLUSIONS Burst fractures of the thoracolumbar junction is a very common condition, treatment of each patient must be individualized. Conservative treatment is recommended for stable fractures without neurological compromise and less than 35° of kyphosis.
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Affiliation(s)
- Mario Cahueque
- Orthopedic Surgeon, Centro Medico Nacional de Occidente, Guadalajara, Mexico
| | - Andrés Cobar
- Orthopedic Surgeon, Centro Medico Nacional de Occidente, Guadalajara, Mexico
| | - Carlos Zuñiga
- Neurosurgeon, Centro Medico Nacional de Occidente, Guadalajara, Mexico
| | - Gustavo Caldera
- Orthopedic and Spine Surgeon, Orthopedics, Centro Medico Nacional de Occidente, Guadalajara, Mexico
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Singh Tveit M, Singh E, Olaussen A, Liew S, Fitzgerald MC, Mitra B. What is the purpose of log roll examination in the unconscious adult trauma patient during trauma reception? Emerg Med J 2016; 33:632-5. [PMID: 27287002 DOI: 10.1136/emermed-2015-205450] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 05/13/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND During assessment after injury, the log roll examination, in particular palpation of the thoracolumbar spine, has low sensitivity for detecting spinal injury. The manoeuvre itself requires a pause during trauma resuscitation. The aim of this study was to assess the utility of the log roll examination in unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar spine injuries. METHODS A retrospective cohort study was undertaken, reviewing the cases of unconscious (Glasgow Coma Scale (GCS) <9) and/or intubated major trauma (Injury Severity Scale (ISS) >12, abbreviated injury scale 2008) patients from the Alfred Trauma Registry, over a 2-year period from January 2011 to December 2012. Log roll examination findings, as documented in the medical record, were compared with CT reports. Out of the 624 screened records, 222 (35.6%) were excluded as the log roll or CT/MRI had not been performed. RESULTS There were a total of 2028 major trauma presentations to the Alfred Hospital Emergency and Trauma Centre during the study period. Excluded cases comprised 147 patients who did not have a documented log roll, and 75 patients who did not have a CT or MRI. Of the 402 cases that met inclusion criteria, 35.3% had a thoracolumbar fracture, and the sensitivity of log roll examination was found to be 27.5%, with a specificity of 91%. The negative likelihood ratio for abnormalities on log roll was low (0.8). CONCLUSIONS Examination of the back in unconscious trauma patients could be limited to visual inspection only to allow identification of penetrating wounds and other soft tissue injuries (including of the posterior scalp) and removal of foreign bodies, in patients planned for CT scans. The low sensitivity and poor negative likelihood ratio suggest that a normal log roll examination does not accurately predict the absence of bony injury to the thoracolumbar spine.
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Affiliation(s)
- Megha Singh Tveit
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Eshana Singh
- Monash University, Melbourne, Victoria, Australia
| | - Alexander Olaussen
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia Monash University, Melbourne, Victoria, Australia Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia National Trauma Research Institute, Melbourne, Victoria, Australia Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - Susan Liew
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Mark C Fitzgerald
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia National Trauma Research Institute, Melbourne, Victoria, Australia Department of Epidemiology & Preventative Medicine, Monash University, Melbourne, Victoria, Australia
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Cason B, Rostas J, Simmons J, Frotan MA, Brevard SB, Gonzalez RP. Thoracolumbar spine clearance: Clinical examination for patients with distracting injuries. J Trauma Acute Care Surg 2016; 80:125-30. [PMID: 26491795 DOI: 10.1097/ta.0000000000000884] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to prospectively assess the sensitivity of clinical examination to screen for thoracolumbar spine (TLS) injury in awake and alert blunt trauma patients with distracting injuries. METHODS From December 2012 to June 2014, all blunt trauma patients older than 13 years were prospectively evaluated as per standard TLS examination protocol at a Level 1 trauma center. Awake and alert patients with Glasgow Coma Scale (GCS) score of 14 or greater underwent clinical examination of the TLS. Clinical examination was performed regardless of distracting injuries. Patients with no complaints of pain or tenderness on examination of the TLS were considered clinically cleared of injury. Patients with distracting injuries, including those clinically cleared and those with complaints of TLS pain or tenderness, underwent computed tomographic scan of the entire TLS. Patients with minor distracting injuries were not considered to have a distracting injury. RESULTS A total of 950 blunt trauma patients were entered, 530 (56%) of whom had at least one distracting injury. Two hundred nine patients (40%) with distracting injuries had a positive TLS clinical examination result, of whom 50 (25%) were diagnosed with TLS injury. Three hundred twenty-one patients (60%) with distracting injuries were initially clinically cleared, in whom 17 (5%) TLS injuries were diagnosed. There were no missed injuries that required surgical intervention, with only four injuries receiving TLS orthotic bracing. This yielded an overall clinical clearance sensitivity for injury of 75% and sensitivity for clinically significant injury of 89%. CONCLUSION In awake and alert blunt trauma patients with distracting injuries, clinical examination is a sensitive screening method for significant TLS injury. Radiologic assessment may be unnecessary for safe clearance of the asymptomatic TLS in patients with distracting injuries. These findings suggest significant potential reduction of both health care cost and patient radiation exposure. LEVEL OF EVIDENCE Diagnostic study, level IV; therapeutic/care management study, level IV.
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Affiliation(s)
- Ben Cason
- From the Department of Surgery (B.C., J.R., J.S., S.B.B.), University of South Alabama, Mobile, Alabama; Department of Surgery (M.A.F.), Texas Health Presbyterian, Dallas, Texas; and Division of Trauma, Surgical Critical Care, Burns (R.P.G.), Loyola University Medical Center, Maywood, Illinois
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Prevalence and "Red Flags" Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice. Phys Ther 2016; 96:305-12. [PMID: 26183589 DOI: 10.2522/ptj.20140525] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 07/05/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND In a small proportion of patients experiencing unspecified back pain, a specified underlying pathology is present. OBJECTIVE The purposes of this study were: (1) to identify the prevalence of physician-specified causes of back pain and (2) to assess associations between "red flags" and vertebral fractures, as diagnosed by the patients' general practitioner (GP), in older adults with back pain. METHODS The Back Complaints in the Elders (BACE) study is a prospective cohort study. Patients (aged >55 years) with back pain were included when consulting their GP. A questionnaire was administered and a physical examination and heel bone densitometry were performed, and the results determined back pain and patient characteristics, including red flags. Participants received a radiograph, and reports were sent to their GP. The final diagnoses established at 1 year were collected from the GP's patient registry. RESULTS Of the 669 participants included, 6% were diagnosed with a serious underlying pathology during the 1-year follow-up. Most of these participants (n=33, 5%) were diagnosed with a vertebral fracture. Multivariable regression analysis showed that age of ≥75 years, trauma, osteoporosis, a back pain intensity score of ≥7, and thoracic pain were associated with a higher chance of getting the diagnosis of a vertebral fracture. Of these variables, trauma showed the highest positive predictive value for vertebral fracture of 0.25 (95% confidence interval=0.09, 0.41) and a positive likelihood ratio of 6.2 (95% confidence interval=2.8, 13.5). A diagnostic prediction model including the 5 red flags did not increase these values. LIMITATIONS Low prevalence of vertebral fractures could have led to findings by chance. CONCLUSIONS In these older adults with back pain presenting in general practice, 6% were diagnosed with serious pathology, mainly a vertebral fracture (5%). Four red flags were associated with the presence of vertebral fracture.
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Zreik NH, Francis I, Ray A, Rogers BA, Ricketts DM. Blunt chest trauma: bony injury in the thorax. Br J Hosp Med (Lond) 2016; 77:72-7. [DOI: 10.12968/hmed.2016.77.2.72] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nasri H Zreik
- Orthopaedic Registrar in the Department of Trauma and Orthopaedics, Aintree University Hospital, Liverpool L9 7AL
| | - Irene Francis
- Medical Student in the Department of Medicine and Dentistry, Brighton University, Brighton
| | - Arun Ray
- Orthopaedic Registrar in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex
| | - Benedict A Rogers
- Consultant Orthopaedic Surgeon in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex
| | - David M Ricketts
- Consultant Orthopaedic Surgeon in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex
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Occupant and Crash Characteristics of Elderly Subjects With Thoracic and Lumbar Spine Injuries After Motor Vehicle Collisions. Spine (Phila Pa 1976) 2016; 41:32-8. [PMID: 26230541 DOI: 10.1097/brs.0000000000001079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Abstract
BACKGROUND The initial diagnostic procedure of severely injured patients in the emergency room (ER) during the primary survey is first and foremost a clinical examination. The clinical S3 guidelines provide recommendations for the treatment of patients with severe and multiple injuries. OBJECTIVES The study was performed to investigate the reliability of clinical key symptoms or red flags registered in the ER that lead to further diagnostic or therapeutic procedures. MATERIAL AND METHODS An evaluation of key symptoms as a synopsis of the current literature considering aspects of probability calculation and medical experience was carried out. RESULTS Key symptoms registered during the clinical examination are not sufficiently safe to be solely relied upon for further diagnostic and therapeutic decisions. This confirms the sense of purpose of the strict approach according to the advanced trauma life support (ATLS) algorithm. Red flags can serve as a warning to focus on relevant injuries early on. A rational imaging diagnostic procedure must follow.
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Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study. J Trauma Acute Care Surg 2015; 78:459-65; discussion 465-7. [PMID: 25710414 DOI: 10.1097/ta.0000000000000560] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Unlike the cervical spine (C-spine), where National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rules can be used, evidence-based thoracolumbar spine (TL-spine) clearance guidelines do not exist. The aim of this study was to develop a clinical decision rule for evaluating the TL-spine after injury. METHODS Adult (≥15 years) blunt trauma patients were prospectively enrolled at 13 US trauma centers (January 2012 to January 2014). Exclusion criteria included the following: C-spine injury with neurologic deficit, preexisting paraplegia/tetraplegia, and unevaluable examination. Remaining evaluable patients underwent TL-spine imaging and were followed up to discharge. The primary end point was a clinically significant TL-spine injury requiring TL-spine orthoses or surgical stabilization. Regression techniques were used to develop a clinical decision rule. Decision rule performance in identifying clinically significant fractures was tested. RESULTS Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15-103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery. CONCLUSION Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury. Addition of age and high-risk mechanism results in a clinical decision-making rule with a sensitivity of 98.9% for clinically significant injuries. LEVEL OF EVIDENCE Diagnostic test, level III.
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Abstract
The most common fractures of the spine are associated with the thoracolumbar junction. The goals of treatment of thoracolumbar fracture are leading to early mobilization and rehabilitation by restoring mechanical stability of fracture and inducing neurologic recovery, thereby enabling patients to return to the workplace. However, it is still debatable about the treatment methods. Neurologic injury should be identified by thorough physical examination for motor and sensory nerve system in order to determine the appropriate treatment. The mechanical stability of fracture also should be evaluated by plain radiographs and computed tomography. In some cases, magnetic resonance imaging is required to evaluate soft tissue injury involving neurologic structure or posterior ligament complex. Based on these physical examinations and imaging studies, fracture stability is evaluated and it is determined whether to use the conservative or operative treatment. The development of instruments have led to more interests on the operative treatment which saves mobile segments without fusion and on instrumentation through minimal invasive approach in recent years. It is still controversial for the use of these treatments because there have not been verified evidences yet. However, the morbidity of patients can be decreased and good clinical and radiologic outcomes can be achieved if the recent operative treatments are used carefully considering the fracture pattern and the injury severity.
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Carter B, Griffith B, Mossa-Basha F, Zintsmaster SA, Patel S, Williams TR, Patton P, Vallee PA. Reformatted images of the thoracic and lumbar spine following CT of chest, abdomen, and pelvis in the setting of blunt trauma: are they necessary? Emerg Radiol 2015; 22:373-8. [PMID: 25666301 DOI: 10.1007/s10140-015-1295-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/04/2015] [Indexed: 11/30/2022]
Abstract
Injuries involving the thoracic and lumbar (TL) spine in the setting of blunt trauma are not uncommon. At our institution, CT of the chest, abdomen, and pelvis (CT CAP) with dedicated reformatted images of the thoracolumbar spine (CT TL) is part of the standard work-up of patients following significant blunt trauma. The purpose of this study was to compare the detection rate of TL spine fractures on routine trauma CT CAP with reformatted CT TL spine images and determine whether these reformatted images detect additional fractures and if these altered patient management. The imaging records of 1000 consecutive patients who received blunt trauma protocol CT CAP with CT TL spine reformats were reviewed to determine identification of TL spine fracture in each report. Fracture type and location were documented. Of the 896 patients, 66 (7.4 %) had fractures of the TL spine identified on either CT CAP or CT TL spine. Of these 66 patients, 40 (60.6 %) had fractures identified on both CT CAP and CT TL spine and 24 (36.4 %) had fractures identified on CT TL spine images alone. Fourteen patients required treatment with surgery or bracing, 4 (28.6 %) of which had fractures identified on reformatted TL spine imaging only. In conclusion, a significant number of fractures are detected on TL spine reformats that are not identified on CT CAP alone, altering patient management in a few cases and suggesting that dedicated TL spine reformats should be a standard part of the work-up of blunt trauma patients.
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Affiliation(s)
- Britton Carter
- Department of Radiology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
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