Thoracolumbar fractures in patients with multiple injuries: diagnosis and treatment-a review of 147 cases

A Critical Appraisal of the Congress of Neurological Surgeons Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma

Background and objective Thoracolumbar spine trauma (TST) is frequently associated with spinal cord injury and other soft tissue and bony injuries. The management of such injuries requires an evidence-based approach. This study used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to assess the methodological quality of clinical guidelines for the management of TST published by the Congress of Neurological Surgeons (CNS). Methods All clinical guidelines on TST published by CNS until 2020 were assessed. Five appraisers from three international centers evaluated the quality of eligible clinical guidelines by using AGREE II. Mean AGREE II scores for each domain were determined. In higher-quality domains, the scores for individual items were analyzed. Results A total of 12 guidelines published by CNS on TST were assessed. Mean scores for all six domains were as follows: Scope and Purpose (75.2%), Stakeholder Involvement (45.4%), Rigor of Development (57.0%), Clarity of Presentation (58.7%), Applicability (16.9%), and Editorial Independence (64.1%). The mean score for the overall quality of all CNS guidelines was 52.9% [95% confidence interval (CI): 52.2-53.5%]. The overall agreement among appraisers was excellent [intra-class correlation coefficients (ICCs) for each guideline ranged from 0.903 to 0.963]. Conclusions CNS guidelines for the management of TST demonstrated acceptable quality across most domains; however, the domains of Applicability and Stakeholder Involvement could be further improved in future guideline updates. The assessors concluded that all guidelines could still be recommended for clinical practice with or without modifications.

Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries

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.

Risk factors for insufficient reduction after short-segment posterior fixation for thoracolumbar burst fractures: Does the interval from injury onset to surgery affect reduction of fractured vertebrae?

BACKGROUND

Many surgeons have encountered patients who could not immediately undergo surgery to treat spinal fractures because they had associated injuries and/or because a complete diagnosis was delayed. For such patients, practitioners might assume that delays could mean that the eventual reduction would be insufficient. However, no report covered risk factors for insufficient reduction of fractured vertebra including duration from injury onset to surgery. The purpose of this study is to investigate the risk factors for insufficient reduction after short-segment fixation of thoracolumbar burst fractures.

METHODS

Our multicenter study included 253 patients who sustained a single thoracolumbar burst fracture and underwent short-segment fixation. We measured the local vertebral body angle (VBA) on roentgenograms, before and after surgery, and then calculated the reduction angle and reduction rate of the fractured vertebra by using the following formula: [Formula: see text] A multiple logistical regression analysis was performed to identify risk factors for insufficient reduction. The factors that we evaluated were age, gender, affected spine level, time elapsed from injury to surgery, inclusion of vertebroplasty with surgery, load-sharing score (LSS), AO classification (type A or B), preoperative VBA, and the ratio of canal compromise before surgery.

RESULTS

There were 140 male and 113 female patients, with an average age of 43 years, and the mean time elapsed between injury and surgery was 3.8 days. The mean reduction angle was 12°, and the mean reduction rate was 76%. The mean LSS was 6.4 points. Multiple linear regression analysis revealed that a higher LSS, a larger preoperative VBA, a younger age, and being female disposed patients to having a larger reduction angle and reduction rate. The time elapsed from injury to surgery had no relation to the quality of fracture reduction in the acute period.

CONCLUSIONS

Our findings indicate that if there is no neurologic deficit, we might not need to hurry surgical reduction of fractured vertebrae in the acute phase.

Radiological outcome of operative treatment with posterior approach in patients with thoracolumbar junction traumatic injuries: A single-center pilot study in a developing country

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.

Indications for Nonsurgical Treatment of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar spine is the most injured spinal region in blunt trauma. Literature on the indications for nonoperative treatment of thoracolumbar fractures is conflicting. The purpose of this systematic review is to clarify the indications for nonsurgical treatment of thoracolumbar fractures. We conducted a systematic literature search between 2010 to 2020 on PubMed/MEDLINE, and Cochrane Central. Up-to-date literature on the indications for nonoperative treatment of thoracolumbar fractures was reviewed to reach an agreement in a consensus meeting of WFNS (World Federation of Neurosurgical Societies) Spine Committee. The statements were voted and reached a positive or negative consensus using the Delphi method. For all of the questions discussed, the literature search yielded 1,264 studies, from which 54 articles were selected for full-text review. Nine studies (4 trials, and 5 retrospective) evaluating 759 participants with thoracolumbar fractures who underwent nonoperative/surgery were included. Although, compression type and stable burst fractures can be managed conservatively, if there is major vertebral body damage, kyphotic angulation, neurological deficit, spinal canal compromise, surgery may be indicated. AO type B, C fractures are preferably treated surgically. Future research is necessary to tackle the relative paucity of evidence pertaining to patients with thoracolumbar fractures.

Early loss of angular kyphosis correction in patients with thoracolumbar vertebral burst (A3-A4) fractures who underwent percutaneous pedicle screws fixation

Purpose

Percutaneous trans-pedicle screws represent a surgical option frequently performed in patients affected by thoracolumbar vertebral burst fractures (A3-A4). The aim of the study was to evaluate the early loss of kyphosis correction and its clinical correlations in a cohort of patients affected by burst spinal fracture treated with percutaneous trans-pedicle screws fixation.

Methods

The present investigation consists in a retrospective one center analysis. The primary outcome was the evaluation of the early loss of correction. Secondary outcomes were the bi-segmental kyphosis change, the clinical outcome and the correlation between clinical outcome and the loss of correction.

Results

Among 435 patients 97 were included in the study. A mean 3.3° of early loss of correction was observed between postoperative and 1 month follow-up evaluations. The mean anterior vertebral body height change was 3.8 mm. No statistical differences were found in clinical and functional outcomes between patients with >2° or <2° of kyphosis loss of correction.

Conclusion

No statistical differences were found between 1 e 6 months postoperative kyphosis loss of correction. The amount of loss of correction seems not to influence clinical outcomes after percutaneous trans-pedicle screw fixation in patients with vertebral burst fractures.

Timing of intervention for spinal injury in patients with polytrauma

OBJECTIVE

The optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores.

METHODS

A narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995-2020) based on the keywords - polytrauma OR multiple trauma AND spine fracture AND timing, present in "All the fields" of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed.

RESULTS

Spine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, "damage control" internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay.

CONCLUSION

Recognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.

Timing of Surgery in Thoracolumbar Spine Injury: Impact on Neurological Outcome

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We aimed to evaluate the improvement in neurological deficit following early versus late decompression and stabilization of thoracolumbar junctional fractures.

METHODS

This is a retrospective evaluation of all patients with a traumatic spinal cord injury (SCI) from T11 to L2 treated at a teaching hospital between 2010 and 2017. Grouped analysis was performed comparing the cohort of patients who received early surgery within 24 hours (group 1) with those operated within 24 to 72 hours (group 2) and more than 72 hours after SCI (group 3). The primary outcome was the change in ASIA (American Spinal Injury Association) motor score at 12-month follow-up.

RESULTS

There were 317 patients (225 males and 92 females with mean age of 31.55 ± 12.43 years). A total of 144, 77, and 96 patients belonged to groups 1, 2, and 3 respectively. Improvement of at least 1 grade on ASIA classification was observed in 80, 45, and 33 patients in groups 1, 2, and 3 respectively (P = .001). Overall, 32, 12, and 10 patients improved ≥2 grades on ASIA classification in groups 1, 2, and 3, respectively (P = .069). On logistic regression analysis, early surgery and severity of initial injury (complete [ASIA A] vs incomplete SCI [ASIA B-D]) were found to significantly influence the potential for neurologic improvement (P = .004 and P < .0001, respectively).

CONCLUSION

We believe that the earlier the decompression, the better. The 72-hour cutoff represents the most promising time window during which surgical decompression has the potential to confer a neuroprotective effect in the setting of incomplete SCI (ASIA B-D) in the distal region of the spinal cord (conus medullaris).

Percutaneous pedicle screw fixation combined with transforaminal endoscopic spinal canal decompression for the treatment of thoracolumbar burst fracture with severe neurologic deficit: A case report

RATIONALE

The most common fractures of the spine are associated with the thoracolumbar junction (T10-L2). And burst fractures make up 15% of all traumatic thoracolumbar fractures, which are often accompanied by neurological deficits and require open surgeries. Common surgeries include either anterior, posterior or a combination of these approaches. Here, we report the first attempt to treat thoracolumbar burst fracture (TLBF) with severe neurologic deficits by percutaneous pedicle screw fixation (PPSF) and transforaminal endoscopic spinal canal decompression (TESCD).

PATIENT CONCERNS

A 46-year-old Chinese woman suffered from severe lower back pain with grade 0 muscle strength of lower limbs, without any sensory function below the injury level, with an inability to urinate or defecate after a motor vehicle accident. Imaging studies confirmed that she had Magerl type A 3.2 L1 burst fracture.

DIAGNOSES

Burst fracture at L1.

INTERVENTIONS

The patient underwent PPSF at the level of T12 to L2, but her neurological function did not fully recover after the operation. One week after the injury, we performed TESCD on her.

OUTCOMES

There was an immediate improvement in her neurological function in just 1 day after 2-stage operation. During the 6-month follow-up period, her neurological functions gradually recovered, and she was able to defecate and urinate. At the last follow-up visit, her spinal cord function was assessed to be at Frankel grade D.

LESSONS

PPSF plus TESCD can achieve complete spinal cord decompression, promote neurological recovery, and is therefore an effective method for the treating lumbar burst fractures with severe neurologic deficits.

Thoracolumbar burst fractures in patients with neurological deficit: Anterior approach versus posterior percutaneous fixation with laminotomy

BACKGROUND

Thoracolumbar burst fractures (TLBFs) are the most common spinal trauma; however, their appropriate management has not yet been determined. In this study, we aimed to compare the clinical and radiological results of percutaneous pedicle screw fixation (PPSF) following posterior decompression technique versus anterior corpectomy and fusion technique for the treatment of TLBFs.

METHODS

A total of 46 patients (2002-2015) with TLBFs were included in this study. The inclusion criteria were a single-level Magerl type A3 burst fracture of the thoracolumbar junctional spine (T12-L2). The patients were divided into two groups; Group A (22 patients) underwent anterior corpectomy and fusion, and Group B (24 patients) underwent PPSF after posterior decompression. Anterior corpectomy and fusion surgery were performed in 22 cases before April 2009, and PPSF following posterior decompression technique was used in 24 cases since then. For radiological assessment, the kyphosis angle was measured preoperatively, early postoperatively, and at the last follow-up using the Cobb angle. Mean correction of the Cobb angle after surgery, and loss of correction between the immediate postoperative and final Cobb angle were calculated accordingly. All neurological deficits were identified in the initial evaluation and graded using the American Spinal Injury Association(ASIA) grading system. Perioperative parameters including operation time, amount of blood loss, and mean hospital stay were also evaluated.

RESULTS

The patients comprised 17 males and 5 females in Group A and 13 males and 11 females in Group B. In terms of the involved levels, there were three cases of T12, twelve L1, and seven L2 in Group A and one case of T12, thirteen L1, and ten L2 in Group B. The mean follow-up duration was 44.9 months in Group A and 14.7 months in Group B. The kyphotic angle was significantly corrected after surgery by 6.4° in Group A (p = 0.001) and 9.2° in Group B (p < 0.001). Among patients with neurological deficit, 11 of 15 in Group A and 20 of 23 in Group B demonstrated improvement by at least one ASIA grade at the final observation. However, there was no significant difference in neurological improvement between the two groups (p = 0.13). Mean operation time was significantly shorter (p < 0.001) and mean blood loss was significantly less (p < 0.001) in Group B than in Group A. Mean hospital stay was also significantly shorter in Group B (p < 0.001).

CONCLUSIONS

Spinal canal decompression through small laminectomy followed by PPSF in the treatment of TLBFs with neurological deficits offers excellent clinical and radiological improvement as well as biomechanical stability. Furthermore, this can be a safe and effective surgical option with the advantage of less invasiveness in the treatment of TLBFs.

The efficacy and safety of multiple-dose intravenous tranexamic acid in reducing perioperative blood loss in patients with thoracolumbar burst fracture

OBJECTIVE

To evaluate the efficacy and safety of tranexamic acid (TXA) for single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach.

PATIENTS AND METHODS

We identified 264 patients with single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach (January 2016-June 2019) at a single center. The cohort was separated into three groups. Group A received 20 mg/kg TXA at 5 min before skin incision and 16 h after first dose; Group B received 20 mg/kg TXA at 5 min before skin incision; Group C received NS at each same time point. The outcomes were evaluated by hidden blood loss (HBL), total blood loss (TBL), intraoperative blood loss (IBL), transfusion rate, maximum hemoglobin (Hb) drop, prethrombotic state molecular markers, liver and renal function, coagulation function, inflammatory factor and adverse events.

RESULTS

The HBL, TBL and maximum Hb drop were significantly lower in Group A than those of Group B and Group C, while the difference between Group B and Group C was statistically significant. The IBL was significantly lower in Group A and Group B than that of Group C. However, there was no significantly difference among the three groups in live and renal function, coagulation function, prethrombotic state molecular markers, transfusion rate and complications during the perioperative period. There was significantly lower level of interleukin-6 (IL-6) in Group A than Group C at the day after surgery, and lower level of C-reactive protein (CRP) at the third day after surgery.

CONCLUSIONS

Intravenous TXA used in the treatment of thoracolumbar burst fracture underwent pedicle screw fixation via Wiltse approach is effective and safe in decreasing perioperative blood loss. The two-dose TXA regimen can further reduce blood loss and alleviate post-operative inflammation response, without affecting prethrombotic state molecular marks and without increasing the risk of complications.

Posterior monoaxial screw fixation combined with distraction-compression technology assisted endplate reduction for thoracolumbar burst fractures: a retrospective study

Background

The management of thoracolumbar burst fractures traditionally involves posterior pedicle screw fixation, but it has some drawbacks. The aim of this study is to evaluate the clinical and radiological outcomes of patients with thoracolumbar burst fractures. They were treated by a modified technique that monoaxial pedicle screws instrumentation and distraction-compression technology assisted end plate reduction.

Methods

From March 2014 to February 2016, a retrospective study including 42 consecutive patients with thoracolumbar burst fractures was performed. The patients had undergone posterior reduction and instrumentation with monoaxial pedicle screws. The fractured vertebrae were also inserted screws as a push point. The distraction -compression technology was used as assisting end plate reduction. All patients were followed up at a minimum of 2 years. These parameters including segmental kyphosis, severity of fracture, neurological function, canal compromise and back pain were evaluated in preoperatively, postoperatively and at the final follow-up.

Results

The average follow-up period was 28.9 ± 4.3 months (range, 24-39mo). No patients had postoperative implant failure at recent follow-up. The mean Cobb angle of the kyphosis was improved from 14.2°to 1.1° (correction rate 92.1%). At final follow-up there was 1.5% loss of correction. The mean preoperative wedge angle was improved from 17.1 ± 7.9°to 4.4 ± 3.7°(correction rate 74.3%). The mean anterior and posterior vertebral height also showed significant improvements postoperatively, which were maintained at the final follow-up(P < 0.05). The mean visual analogue scale (VAS) scores was 8 and 1.6 in preoperation and at the last follow-up, and there was significant difference (p < 0.05).

Conclusion

Based on our experience, distraction-compression technology can assist reduction of collapsed endplate directly. Satisfactory fracture reduction and correction of segmental kyphosis can be achieved and maintained with the use of monoaxial pedicle screw fixation including the fractured vertebra. It may be a good treatment approach for thoracolumbar burst fractures.

Primary Imaging Test for Suspected Traumatic Thoracolumbar Spine Injury: 2017 Guidelines by the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency

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.

Thromboembolic Events After Traumatic Vertebral Fractures: An Analysis of 190,192 Patients

STUDY DESIGN

Retrospective cohort study OBJECTIVE.: To determine the rate of venous thromboembolism event (VTE) and risk factors for their occurrence in patients with vertebral fractures.

SUMMARY OF BACKGROUND DATA

Deep vein thrombosis or pulmonary embolism (VTE) events are a significant source of potentially preventable morbidity and mortality in trauma patients. In patients with traumatic vertebral fractures, a common high-energy injury sometimes resulting in spinal cord injury, there is debate about what factors may be associated with such VTEs.

METHODS

All patients with vertebral fractures in the American College of Surgeons National Trauma Data Bank Research Data Set (NTDB RDS) from years 2011 and 2012 were identified. Multivariate logistic regression was used to determine factors associated with the occurrence of VTE while considering patient factors, injury characteristics, and hospital course.

RESULTS

A total of 190,192 vertebral fractures patients were identified. The overall rate of VTE was 2.5%. In multivariate analysis, longer inpatient length of stay was most associated with increased VTEs with an odds ratio (OR) of up to 96.60 (95% CI: 77.67 - 129.13) for length of stay longer than 28 days (compared to 0 - 3 days). Additional risk factors in order of decreasing odds ratios were older age (OR of up to 1.65 [95% CI: 1.45 - 1.87] for patients age 70 - 79 years [compared to age 18 - 29 years]), complete spinal cord injuries (OR: 1.49 [95% CI: 1.31 - 1.68]), cancer (OR: 1.37 [95% CI: 1.25 - 1.50]), and obesity (OR: 1.32 [95% CI: 1.18 - 1.48]). Multiple associated non-spinal injuries were also associated with increased rates of VTE.

CONCLUSION

While the overall rate of VTE is relatively low after vertebral fractures, longer LOS and other defined factors to lesser extents were predisposing factors. By determining patients at greatest risk, protocols to prevent such adverse outcomes can be developed and optimized.

LEVEL OF EVIDENCE

3.

Thoracolumbar Burst Fractures

Thoracolumbar burst fractures are high-energy vertebral injuries, which commonly can be treated nonoperatively. Consideration of the injury pattern, extent of comminution, neurological status, and integrity of the posterior ligamentous complex may help determine whether operative management is appropriate. Several classification systems are contingent upon these factors to assist with clinical decision-making. A multitude of operative procedures have been shown to have good radiographic and clinical outcomes with extended follow-up, and treatment choice should be based on the individual's clinical and radiographic presentation.

Comparison of Wiltse's paraspinal approach and open book laminectomy for thoracolumbar burst fractures with greenstick lamina fractures: a randomized controlled trial

Background

Posterior short-segment pedicle screw fixation is used to treat thoracolumbar burst fractures. However, no randomized controlled studies have compared the efficacy of the two approaches––the Wiltse’s paraspinal approach and open book laminectomy in the treatment of thoracolumbar burst fractures with greenstick lamina fractures.

Materials and methods

Patients with burst fractures of the thoracolumbar spine without neurological deficit were randomized to receive either the Wiltse’s paraspinal approach (group A, 24 patients) or open book laminectomy (group B, 23 patients). Patients were followed postoperatively for average of 27.4 months. Clinical and radiographic data of the two approaches were collected and compared.

Results

Our results showed the anterior segmental height, kyphotic angle, visual analog scale (VAS) score, and Smiley-Webster Scale (SWS) score significantly improved postoperatively in both groups, indicating that both the Wiltse’s paraspinal approach and open book laminectomy can effectively treat thoracolumbar burst fractures with greenstick lamina fractures. The Wiltse’s paraspinal approach was found to have significantly shorter operating time, less blood loss, and shorter length of hospital stay compared to open book laminectomy. However, there were two (2/24) patients in group A that had neurological deficits postoperatively and required a second exploratory operation. Dural tears and/or cauda equina entrapment were subsequently found in four patients in group B and all two patients of neurological deficits in group A during operation. No screw loosening, plate breakage, or other internal fixation failures were found at final follow-up.

Conclusions

The results demonstrated that either of the two surgical approaches can achieve satisfactory results in treating thoracolumbar burst fractures in patients with greenstick lamina fractures. However, if there is any clinical or radiographic suspicion of a dural tear and/or cauda equina entrapment pre-operation, patients should receive an open book laminectomy to avoid a second exploratory operation. More research is still needed to optimize clinical decision-making regarding surgical approach.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0743-z) contains supplementary material, which is available to authorized users.

Timing of Operative Intervention in Traumatic Spine Injuries Without Neurological Deficit

BACKGROUND

Numerous studies have demonstrated the benefits of early decompression and stabilization in unstable spine injuries with incomplete neurological deficits. However, a clear consensus on timing to operative intervention still does not exist in those with a normal neurological exam and unstable spine.

OBJECTIVE

To determine the optimal timing of operative intervention in traumatic spine injuries without neurological deficit.

METHODS

Retrospective chart review at a single institution was performed including patients with traumatic spine injuries without neurological deficit admitted from December 2001 to August 2012. Estimated intraoperative blood loss (EBL), in-hospital complications, postoperative hospital length of stay (HLOS), intensive care unit length of stay (ICULOS), and ventilator days were recorded. Delayed surgery was defined as surgery 72 h after admission.

RESULTS

A total of 456 patients were included for analysis. There was a trend towards statistical significance between the time to operative intervention and EBL in bivariate analysis (P = .07). In the risk-adjusted multivariable analysis delayed vs early surgery was not associated with increased EBL or complications. Delayed surgery was associated with increased ICULOS (odds ratio [OR] = 2.19; 95% confidence interval [CI]: 1.38-3.51; P = .001), ventilator days (OR = 2.09; 95% CI: 1.28-3.43; P = .004), and increased postoperative HLOS (OR = 1.84; 95% CI: 1.22-2.76; P = .004).

CONCLUSION

Earlier operative intervention was associated with decreased ICULOS, ventilator days, and postoperative HLOS and did not show a statistically significant increase in EBL or complications. Earlier operative intervention for traumatic spine injuries without neurological deficit provides better outcomes compared to delayed surgery.

A comparative study of single-stage transpedicular debridement, fusion, and posterior long-segment versus short-segment fixation for the treatment of thoracolumbar spinal tuberculosis in adults: minimum five year follow-up outcomes

DESIGN

This a retrospective study in single centre.

OBJECTIVE

The objective of this retrospective clinical study is to compare the long-term clinical efficacy of posterior long-segment and short-segment fixation with single-stage transpedicular debridement and fusion for the treatment of thoracolumbar spinal tuberculosis in adults.

METHODS

Sixty-six cases of thoracolumbar tuberculosis were treated by single-stage transpedicular debridement, bone graft fusion, and pedicle screw fixation. Thirty-five cases were under long-segment fixation (group A) and 31 cases were under short-segment fixation (group B). These patients were followed up for a minimum of five years. The clinical and radiographic results for these patients were analyzed and compared.

RESULTS

All 66 patients were completely cured during the follow-up. All patients had significant improvement of neurological condition and visual analogue scale pain scores at the final follow-up. The average operation duration and blood loss in group A were more than that in group B. Kyphosis Cobb angle of both groups was significantly corrected after surgical management. The correction rate of Cobb angle in group A was significantly higher than that in group B at the time of immediate post-operative period or the last follow-up (P < 0.05). The correction loss of group A was significantly less than that in group B (P < 0.05).

CONCLUSION

Both posterior long-segment and short-segment pedicle screw fixations for the treatment of thoracolumbar spinal tuberculosis have significant effects in the correction of kyphosis and the improvement of neurological function. Although the blood loss and operation time of long-segment fixation were more than that of short-segment fixation, long-segment fixation was superior to the short-segment fixation in the correction of kyphosis and the maintenance of spinal stability, especially in the prevention of long-term correction loss.

[Posterior short-segment fixation including the fractured vertebra for severe unstable thoracolumbar fractures]

Objective

To discuss the effectiveness of posterior short-segment fixation including the fractured vertebra for severe unstable thoracolumbar fractures using pedicle screw fixation.

Methods

Between May 2008 and July 2013, 52 patients of severe unstable thoracolumbar fractures were treated through posterior short-segment fixation including the fractured vertebra using pedicle screw fixation. There were 33 males and 19 females with an age of 21-56 years (mean, 37.9 years). The causes of thoracolumbar burst fractures included fall from height in 32 cases, traffic accidents in 16 cases, and others in 4 cases. The load sharing classification (LSC) score was 7-9 (mean, 7.85). The levels involved included T ₁₁ in 4 cases, T ₁₂ in 19 cases, L ₁ in 25 cases, and L ₂ in 4 cases. According to Frankel classification, there were 2 cases of grade A, 4 cases of grade B, 8 cases of grade C, 11 cases of grade D, and 27 cases of grade E. The rate of spinal canal occupying was 24.2%-76.7% (mean, 47.1%). The time from injury to operation was 3-5 days (mean, 3.6 days). The effectiveness was assessed by the changes of injured vertebral Cobb angle, anterior vertebral height, and the Frankel grading at pre- and post-operation.

Results

The operation time was 85-127 minutes (mean, 106.5 minutes). The intraoperative blood loss was 90-155 mL (mean, 137.6 mL). All the incision healed at first intension. Forty-seven patients were followed up 19-27 months (mean, 23.2 months), and no incision infection, screw loosening, or other internal fixation failures was found during follow-up. The injured vertebral Cobb angle and anterior vertebral height at immediate after operation or at last follow-up were significantly improved when compared with preoperative values ( P<0.001). There was a loss of injured vertebral Cobb angle and anterior vertebral height at last follow-up, but no significant difference was found between at immediate after operation and at last follow-up ( P>0.05). The Frankel grade improved by 0-2 grades at last follow-up, showing significant difference when compared with preoperative grades ( Z=15.980, P=0.003).

Conclusion

Posterior short-segment fixation including the fractured vertebra for severe unstable thoracolumbar fractures (LSC≥7) using pedicle screw fixation can correct the kyphosis deformity, restore vertebral body height, and aviod the need of anterior reconstruction.

The Relationship between Superior Disc-Endplate Complex Injury and Correction Loss in Young Adult Patients with Thoracolumbar Stable Burst Fracture

Background

To determine the relationship between superior disc-endplate complex injury and correction loss after surgery in a group of young adult patients with a stable thoracolumbar burst fracture.

Methods

The study group was comprised of young adult patients who had undergone short-segment posterior fixation and bone grafting under the diagnosis of a stable thoracolumbar burst fracture from March 2008 to February 2014. Follow-up was available for more than 1 year. Before surgery, magnetic resonance imaging was performed to determine injury to the anterior longitudinal ligament, posterior longitudinal ligament, and superior and inferior intervertebral discs and endplates. Correction loss was evaluated by the Cobb angle, intervertebral disc height, upper intervertebral disc angle, vertebral wedge angle, and vertebral body height.

Results

No significant relation was noted between correction loss and an injury to the anterior longitudinal ligament, posterior longitudinal ligament, inferior intervertebral disc/endplate, and fracture site, whereas an injury to the superior endplate alone and superior disc-endplate complex showed a significant association. Specifically, a superior intervertebral disc-endplate complex injury showed statistically significant relation to postoperative changes in Cobb angle (p = 0.026) and vertebral wedge angle (p = 0.047).

Conclusions

A superior intervertebral disc-endplate complex injury may have an influence on the prognosis after short-segment fixation in young adult patients with a stable thoracolumbar burst fracture.

Imaging in paediatric spinal injury

Background

Paediatric spinal injury is rare and exhibits many unique features. Attending clinicians and radiologists often lack knowledge, expertise and experience in dealing with a potential injury to the paediatric spine. Within the paediatric age range itself there are different age-dependent mechanisms that can injure the paediatric spine. Moreover, the anatomical features and degree of osseous maturity of the developing paediatric spine determine the biomechanical characteristics which promote unique patterns of spinal injury in each paediatric age group.

Methods

An expert illustrated narrative review of the literature.

Results

Multiple factors make the imaging interpretation of the injured paediatric spine challenging. Each imaging modality has strengths and weaknesses in depicting spinal anatomy which vary with the type of spinal injury and age of the paediatric patient.

Conclusions

Attending doctors need to be familiar with the imaging appearances of the normal paediatric spine, its normal variants as well as the imaging features characteristics of paediatric spinal injury seen on radiographs, computed tomography and magnetic resonance imaging.

Short Segment versus Long Segment Pedicle Screws Fixation in Management of Thoracolumbar Burst Fractures: Meta-Analysis

Posterior pedicle screw fixation has become a popular method for treating thoracolumbar burst fractures. However, it remains unclear whether additional fixation of more segments could improve clinical and radiological outcomes. This meta-analysis was performed to evaluate the effectiveness of fixation levels with pedicle screw fixation for thoracolumbar burst fractures. MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Springer, and Google Scholar were searched for relevant randomized and quasirandomized controlled trials that compared the clinical and radiological efficacy of short versus long segment for thoracolumbar burst fractures managed by posterior pedicle screw fixation. Risk of bias in included studies was assessed using the Cochrane Risk of Bias tool. Based on predefined inclusion criteria, Nine eligible trials with a total of 365 patients were included in this meta-analysis. Results were expressed as risk difference for dichotomous outcomes and standard mean difference for continuous outcomes with 95% confidence interval. Baseline characteristics were similar between the short and long segment fixation groups. No significant difference was identified between the two groups regarding radiological outcome, functional outcome, neurologic improvement, and implant failure rate. The results of this meta-analysis suggested that extension of fixation was not necessary when thoracolumbar burst fracture was treated by posterior pedicle screw fixation. More randomized controlled trials with high quality are still needed in the future.

Management and Outcome Analysis of Pediatric Unstable Thoracolumbar Spine Injury: Large Surgical Series with Literature Review

Pediatric thoracolumbar spine fractures are considered rare injuries with paucity of publication across the globe. Further, spine injuries in children are comparatively rarer, and pediatric spine differs from adults, both biomechanically and anatomically; so, adult spine management strategy cannot be applied to pediatric cases, and exact guidelines for management of pediatric spinal injury is lacking. The current study is undertaken to study epidemiology, surgical management, and outcome of pediatric dorsolumbar unstable spine injury. A total of 25 pediatric patients were analyzed retrospectively with thoracic, thoracolumbar junction and lumbar spine injuries, who were managed surgically at our institute since June 2008, formed the cohort of the present study. There were 19 males and six females with a mean age 14.8 years. Clinically, complete spinal cord injuries were observed in 11 (44%), and rest 14 had incomplete injury. Most common mode of injury was fall (76%) in contrast to the western countries and the thoracolumbar junction was the most common affected site. Among all patients who underwent surgical intervention, 68% cases had posterior decompression and pedicle screw fixation. Mean duration of hospital stay was 18 ± 31 days. The mean follow-up period was 13.83 ± 5.97 months. In incomplete neurological injury group, a total of 13 patients showed neurological improvement, out of which four cases improved by two Frankel grades, eight patients improved by at least 1 grade, and rest one by Grade 3 (Frankel Grade B to E). Neurological outcome was statistically significant in relation to the level of fracture (P - 0.03) and preoperative Frankel grade, however, other factors, for example, gender, mode of injury, type of fracture, various surgical approaches with instrumentation, and correction of kyphotic deformity were found to be statistically nonsignificant. Surgical management of unstable pediatric dorsolumbar spine is a safe and an effective procedure which can provide good neurological outcome. The current study is one of largest series of cases managed surgically in this part of the world.

The epidemiology of thoracolumbar trauma: A meta-analysis

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.

Creating reproducible thoracolumbar burst fractures in human specimens: an in vitro experiment

OBJECT

The treatment of traumatic burst fractures unaccompanied by neurological impairment remains controversial and ranges from conservative management to 360° fusion. Because of the heterogeneity of fracture types, classification systems, and treatment options, comparative biomechanical studies might help to improve our knowledge. The aim of the current study was to create a standardized fracture model to investigate burst fractures in a multisegmental setting.

METHODS

A total of 28 thoracolumbar fresh-frozen human cadaveric spines were used. The spines were dissected into segments (T11–L3). The T-11 and L-3 vertebral bodies were embedded in Technovit 3040 (cold-curing resin for surface testing and impressions). To simulate high energy, a metallic drop tower was designed. Stress risers were used to ensure comparable fractures. CT scans were acquired before and after fracture. All fractures were classified using the AO/OTA classification.

RESULTS

The preparation and embedding of the spine segments worked well. No repositioning or second embedding of the specimen, even after fracture, was required. It was possible to create single burst fractures at the L-1 level in all 28 spine segments. Among the 28 fractures there were 16 incomplete burst fractures (Type A3.1), 8 burst-split fractures (Type A3.2), and 4 complete burst fractures (Type A3.3). The differences before and after fracture for stiffness and for anterior, posterior, and central heights were all significant (p < 0.05).

CONCLUSIONS

The ability to create reproducible burst fractures of a single vertebral body in a thoracolumbar spine segment may serve as a basis for future biomechanical studies that will provide better understanding of mechanical properties or fixation techniques.

Demographics of Thoracolumbar Fracture in Indian Population Presenting to a Tertiary Level Trauma Centre

Study Design

Prospective, cross-sectional, observational study.

Purpose

Spine traumata are devastating injuries, which may result in serious disabilities and dire consequences. The current study involves a detailed analysis and description of patients, who were operated at a tertiary care, urban level 1 Spine Centre in India.

Overview of Literature

Various studies in literature have discussed the epidemiology and patterns of these injuries in trauma patients. However, literature describing the demographic profile and distribution of these traumata in the Indian population is scarce.

Methods

The current study was conducted as a prospective trial involving patients, who were treated at our Spine Centre in India between July 2009 to December 2012. We studied 92 patients with thoraco-lumbar spine fracture, who were operated with short or long segment posterior stabilization. Epidemiological details, pre- and post-hospitalisation care received and other injury pattern factors were studied.

Results

Fall from height (46 patients, 50%) was the most common mechanism observed in the patients. Sixty-three percent injuries belonged to AO type A fractures, while 16.2% and 19.4% of the patients had suffered from AO types B and C injuries, respectively.

Conclusions

We identified interesting epidemiological data and prevailing inadequacies in Emergency Spine care management in the study patients. These observations could facilitate implementation of the changes required to improve current standards of patient care.

Damage control in thoracic and lumbar unstable fractures in polytrauma. Systematic review

<p>The objective of this systematic review was to integrate the information from existing studies to determine the level of evidence and grade of recommendation of the implementation of damage control in unstable thoracic and lumbar fractures in polytraumatized patients. Eighteen papers were collected from different databases by keywords and Mesh terms; the level of evidence and grade of recommendation, the characteristics of the participants, the time of fracture fixation, the type of approach and technique used, the length of stay in the intensive care unit, the days of dependence on mechanical ventilator, and the incidence of complications in patients were assessed. The largest proportion of the studies were classified as level 4 evidence and grade C of recommendation which is favorable to the implementation of damage control in unstable thoracic and lumbar fractures in polytraumatized patients as a positive recommendation, although not conclusive. Most papers advocate fracture stabilization within 72 hours of the injury which is associated with a lower incidence of complications, hospital stay, stay in the intensive care unit and lower mortality.</p>

Predictive factors for a kyphosis recurrence following short-segment pedicle screw fixation including fractured vertebral body in unstable thoracolumbar burst fractures

Objective

The technique of short segment pedicle screw fixation (SSPSF) has been widely used for stabilization in thoracolumbar burst fractures (TLBFs), but some studies reported high rate of kyphosis recurrence or hardware failure. This study was to evaluate the results of SSPSF including fractured level and to find the risk factors concerned with the kyphosis recurrence in TLBFs.

Methods

This study included 42 patients, including 25 males and 17 females, who underwent SSPSF for stabilization of TLBFs between January 2003 and December 2010. For radiologic assessments, Cobb angle (CA), vertebral wedge angle (VWA), vertebral body compression ratio (VBCR), and difference between VWA and Cobb angle (DbVC) were measured. The relationships between kyphosis recurrence and radiologic parameters or demographic features were investigated. Frankel classification and low back outcome score (LBOS) were used for assessment of clinical outcomes.

Results

The mean follow-up period was 38.6 months. CA, VWA, and VBCR were improved after SSPSF, and these parameters were well maintained at the final follow-up with minimal degree of correction loss. Kyphosis recurrence showed a significant increase in patients with Denis burst type A, load-sharing classification (LSC) score >6 or DbVC >6 (p<0.05). There were no patients who worsened to clinical outcome, and there was no significant correlation between kyphosis recurrence and clinical outcome in this series.

Conclusion

SSPSF including the fractured vertebra is an effective surgical method for restoration and maintenance of vertebral column stability in TLBFs. However, kyphosis recurrence was significantly associated with Denis burst type A fracture, LSC score >6, or DbVC >6.

Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients

BACKGROUND

Because of a lack of evidence, the appropriate timing of surgical stabilization of thoracic and lumbar spine injuries in severely injured patients is still controversial. Data of a large international trauma register were analyzed to investigate the medical care situation of unstable spinal column fractures in patients with multiple injuries, so as to examine the outcome related to timing of surgical stabilization.

METHODS

Data sets of the Trauma Registry of German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (1993-2010) were analyzed. The Trauma Registry of DGU is a prospective, multicenter register that provides information on severely injured patients. All patients with an Injury Severity Score (ISS) of 16 or greater caused by blunt trauma, subsequent treatment of 7 days or more, 16 years or older, and thoracic or lumbar spine injuries (spine Abbreviated Injury Scale [AIS] score ≥ 2) were included in our analysis. Patients with relevant spine injuries classified as having a spine AIS score of 3 or greater were further analyzed in terms of whether they got early (<72 hours) or late (>72 hours) surgical treatment due to unstable spinal column fractures.

RESULTS

Of 24,974 patients, 8,994 (36.0%) had documented spinal injuries (spine AIS score ≥ 2). A total of 1,309 patients who sustained relevant thoracic spine injuries (spine AIS score ≥ 3) and 994 patients who experienced lumbar spine trauma and classified as having spine AIS score of 3 or greater were more precisely analyzed. Of these, 68.2% and 71.0%, respectively, received an early thoracic or lumbar spine fixation. With an increase in spinal injury severity, an increase in early stabilization in the thoracic and lumbar spine was seen. In the group of patients with early surgical stabilization, significantly shorter hospital stays, shorter intensive care unit stays, fewer days on mechanical ventilation, and lower rates of sepsis were seen. In the case that additional body regions were affected, for example, when patients were critically ill, a delayed spinal stabilization was more often performed.

CONCLUSION

A spinal stabilization at an early stage (<72 hours) is presumed to be beneficial. Although some patients may require delay due to necessary medical improvement, every reasonable effort should be made to treat patients with instable spinal column fractures as soon as possible. If an early surgical treatment is feasible, severely injured patients may benefit from a shorter period of hospital treatment and a lower rate of complications.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Clinical results of early stabilization of spine fractures in polytrauma patients

PURPOSE

The purpose of study was to evaluate the clinical results of early stabilization of spine fractures in polytrauma patients.

MATERIALS AND METHODS

Between August 2003, and May 2012, 166 polytrauma patients with thoracolumbar spine fractures were included. Patients were divided into 2 groups according to injury-to-operation time (time cut-off, 72 hours). Patients were also subdivided into 4 groups according to injury severity score (ISS), and the clinical course was evaluated.

RESULTS

Group A showed shorter hospital length of stay, intensive care unit, and ventilator days than group B. For each of these categories, the differences between the 2 groups were statistically significant (P=.004, P=.044, and P=.043). Patients with moderate to severe injury (ISS, ≥26), those who were treated with early stabilization showed shorter hospital length of stay, intensive care unit, and ventilator days than the patients with mild to moderate injury (ISS, <26), and the differences were statistically significant (P=.004, P=.006, and P=.006).

CONCLUSION

Polytrauma patients whose spine fractures were stabilized within 72 hours had better clinical outcomes than those with late stabilization. In addition, more severely injured patients (ISS, ≥26) benefited more from early stabilization.

Management of thoracolumbar spine fractures

BACKGROUND CONTEXT

Traumatic fractures of the spine are most common at the thoracolumbar junction and can be a source of great disability.

PURPOSE

To review the most current information regarding the pathophysiology, injury pattern, treatment options, and outcomes.

STUDY DESIGN

Literature review.

METHODS

Relevant articles, textbook chapters, and abstracts covering thoracolumbar spine fractures with and without neurologic deficit from 1960 to the present were reviewed.

RESULTS

The thoracolumbar spine represents a unique system from a skeletal as well as neurological standpoint. The rigid rib-bearing thoracic spine articulates with the more mobile lumbar spine at the thoracolumbar junction (T10 - L2), the site of most fractures. A complete examination includes a careful neurologic examination of both motor and sensory systems. CT scans best describe bony detail while MRI is most efficient at describing soft tissues and neurological structures. The most recent classification system is that of the new Thoracolumbar Injury Classification and Severity Score. The different fracture types include compression fractures, burst fractures - both stable and unstable -, flexion-distraction injuries and fracture dislocations. Their treatment, both operative and non-operative depends on the degree of bony compromise, neurological involvement, and the integrity of the posterior ligamentous complex. Minimally invasive approaches to the care of thoracolumbar injuries have become more popular, thus, the evidence regarding their efficacy is presented. Finally, the treatment of osteoporotic fractures of the thoracolumbar spine is reviewed, including vertebroplasty and kyphoplasty, their risks and controversies, and senile burst fractures, as well.

CONCLUSIONS

Thoracolumbar spine fractures remain a significant source of potential morbidity. Advances in treatment have minimized the invasiveness of our surgery and in certain stable situations, eliminated it all together.

Percutaneous short-segment pedicle screw placement without fusion in the treatment of thoracolumbar burst fractures: is it effective?: comparative study with open short-segment pedicle screw fixation with posterolateral fusion

BACKGROUND

Since introduction of the pedicle screw-rod system, short-segment pedicle screw fixation has been widely adopted for thoracolumbar burst fractures (TLBF). Recently, the percutaneous pedicle screw fixation (PPSF) systems have been introduced in spinal surgery; and it has become a popularly used method for the treatment of degenerative spinal disease. However, there are few clinical reports concerning the efficacy of PPSF without fusion in treatment of TLBF. The purpose of this study was to determine the efficacy and safety of short-segment PPSF without fusion in comparison to open short-segment pedicle screw fixation with bony fusion in treatment of TLBF.

METHODS

This study included 59 patients, who underwent either percutaneous (n = 32) or open (n = 27) short-segment pedicle screw fixation for stabilization of TLBF between December 2003 and October 2009. Radiographs were obtained before surgery, immediately after surgery, and at the final follow-up for assessment of the restoration of the spinal column. For radiologic parameters, Cobb angle, vertebral wedge angle, and vertebral body compression ratio were assessed on a lateral thoracolumbar radiograph. For patient's pain and functional assessment, the visual analogue scale (VAS), the Frankel grading system, and Low Back Outcome Score (LBOS) were measured. Operation time, and the amount of intraoperative bleeding loss were also evaluated.

FINDINGS

In both groups, regional kyphosis (Cobb angle) showed significant improvement immediately after surgery, which was maintained until the last follow up, compared with preoperative regional kyphosis. Postoperative correction loss showed no significant difference between the two groups at the final follow-up. In the percutaneous surgery group, there were significant declines of intraoperative blood loss, and operation time compared with the open surgery group. Clinical results showed that the percutaneous surgery group had a lower VAS score and a better LBOS at three months and six months after surgery; however, the outcomes were similar in the last follow-up.

CONCLUSIONS

Both open and percutaneous short-segment pedicle fixation were safe and effective for treatment of TLBF. Although both groups showed favorable clinical and radiologic outcomes at the final follow-up, PPSF without bone graft provided earlier pain relief and functional improvement, compared with open TPSF with posterolateral bony fusion. Despite several shortcomings in this study, the result suggests that ongoing use of PPSF is recommended for the treatment of TLBF.

Usefulness of full spine computed tomography in cases of high-energy trauma: a prospective study

INTRODUCTION

At this hospital, computed tomography (CT) of the full spine is performed on all patients who have sustained high-energy trauma because spinal fractures can be overlooked by referring only to clinical findings and plain X-rays of the spine. The goal of this study is to prospectively detect the occurrence of spinal fractures in cases of high-energy trauma using full spine CT and to evaluate the usefulness of it.

MATERIALS AND METHODS

Subjects were 179 patients (134 male, 45 female) who were deemed to have sustained high-energy trauma in the 21-month period starting in September 2007. Spinal fractures initially revealed by CT were studied in detail.

RESULTS

Spinal fractures were found in 54 patients (30.2 %); 19 patients had stable fractures, and 41 had unstable fractures. Forty patients had concomitant injuries to organs in addition to spinal injury; these patients had an average Injury Severity Score of 20.2 (4-70). Of 16 patients with a cervical fracture, 6 (37.5 %) had a fracture that did not appear on plain X-rays of the cervical and that was first identified by CT. Of 43 patients with a thoracolumbar fracture, 6 (14.0 %) had a fracture that would have been difficult to detect if a full spine CT had not been done.

CONCLUSION

In patients who have sustained high-energy trauma, spinal fractures may be overlooked during primary care by a diagnosis based only on plain X-rays and clinical manifestations. Therefore, patients who have sustained high-energy trauma should be evaluated with full spine CT during primary care.

Fractures of the thoracic spine in patients with minor trauma: comparison of diagnostic accuracy and dose of biplane radiography and MDCT

OBJECTIVES

To investigate the accuracy of biplane radiography in the detection of fractures of the thoracic spine in patients with minor trauma using multidetector computed tomography (MDCT) as the reference and to compare the dose of both techniques.

METHODS

107 consecutive trauma patients with suspected fractures of the thoracic spine on physical examination were included. All had undergone biplane radiography first, followed by a MDCT scan between October 2008 and October 2012. A fourfold table was used for the classification of the screening test results. Both the Chi-square test (χ(2)) and the mean dose-length product (DLP) were used to compare the diagnostic methods.

RESULTS

MDCT revealed 77 fractures in 65/107 patients (60.7%). Biplane radiography was true positive in 32/107 patients (29.9%), false positive in 19/107 patients (17.8%), true negative in 23/107 (21.5%) and false negative in 33/107 patients (30.8%), showing a sensitivity of 49.2%, a specificity of 54.7%, a positive predictive value (PPV) of 62.7%, a negative predictive value (NPV) of 41.1%, and an accuracy of 51.4%. The presence of a fracture on biplane radiography was highly statistical significant, if this was simultaneously proven by MDCT (χ(2)=7.6; p=0.01). None of the fractures missed on biplane radiography was unstable. The mean DLP on biplane radiography was 14.5mGycm (range 1.9-97.8) and on MDCT 374.6mGycm (range 80.2-871).

CONCLUSIONS

The sensitivity and the specificity of biplane radiography in the diagnosis of fractures of the thoracic spine in patients with minor trauma are low. Considering the wide availability of MDCT that is usually necessary for taking significant therapeutic steps, the indication for biplane radiography should be very restrictive.

CT scanning reduces the risk of missing a fracture of the thoracolumbar spine

The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of ‘missed injury’.

We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk.

Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury.

Principles of management of thoracolumbar fractures

There is little consensus on treatment of thoracolumbar fractures, which are one of the most controversial areas in spine surgery. The great variations in clinical decision making may come from differences in evaluation of spine stability with these fractures. Few high-quality studies concerning optimal treatment of thoracolumbar fractures have been conducted. This article reviews the conflicting results and recommendations for management of thoracolumbar fractures of currently published reports. Specifically, it addresses issues regarding evaluation of stability, indications for operative treatment, timing of surgery, surgical approach, and fusion length.

Current management review of thoracolumbar cord syndromes

BACKGROUND CONTEXT

Injuries to the thoracolumbar spine may lead to a complex array of clinical syndromes that result from dysfunction of the anterior motor units, lumbosacral nerve roots, and/or spinal cord. Neurologic dysfunction may manifest in the lower extremities as loss of fine and gross motor function, touch, pain, temperature, and proprioceptive and vibratory sense deficits. Two clinical syndromes sometimes associated with these injuries are conus medullaris syndrome (CMS) and cauda equina syndrome (CES).

PURPOSE

To review the current management of thoracolumbar spinal cord injuries.

STUDY DESIGN

Literature review.

METHODS

Index Medicus was used to search the primary literature for articles on thoracolumbar injuries. An emphasis was placed on the current management, controversies, and newer treatment options.

RESULTS/CONCLUSIONS

After blunt trauma, these syndromes may reflect a continuum of dysfunction rather than a distinct clinical entity. The transitional anatomy at the thoracolumbar junction, where the conus medullaris is present, makes it less likely that a "pure" CMS or CES syndrome will occur and more likely that a "mixed" injury will. Surgical decompression is the mainstay of treatment for incomplete spinal cord injury (SCI) and incomplete CMS and CES. The value of timing of surgical intervention in the setting of incomplete SCI is unclear at this time. This review summarizes the recent information on epidemiology, pathophysiology, diagnosis, and controversies in the management of thoracolumbar neurologic injury syndromes.

Pediatric multilevel spine injuries: an institutional experience

OBJECT

Spinal column trauma is relatively uncommon in the pediatric population, representing 1-2% of all pediatric fractures. However, pediatric spinal injury at more than one level is not uncommon. The purpose of this study was to evaluate the mechanisms and patterns of the injury and factors affecting management and outcomes of pediatric multilevel spine injuries.

PATIENTS AND METHODS

Patients with pediatric spine injury (183) were retrospectively reviewed. Patients (28 boys, 20 girls; mean age 12.8 years; range 3 to 16 years) identified with multilevel spinal injuries were 48 (26.2%): 7 patients (14.5%) were between 3 and 9 years of age, and 41 patients (85.5%) were between 9 and 16 years of age. Of the 48 patients, 30 (62.5%) were at contiguous levels and 18 (37.5%) were at noncontiguous. A total of 126 injured vertebrae were diagnosed. The cervical region alone was most frequently (31.2%) involved, and the thoracic region alone was the least frequently involved (12.5%). Overall, 73% of patients were neurologically intact, 4.1% had incomplete spinal cord injury (SCI), and 8.3% had complete SCI. Treatment was conservative in 36 (75%) patients. Surgical treatments were done in 12 patients (25%). Postoperatively, one patient (16.6%) with initial neurologic deficit improved. The overall mortality rate was 6.2%.

CONCLUSIONS

Multilevel spine injuries are most common in children between 9 and 16 years of age and are mainly located in the cervical region. The rostral injury was most often responsible for the neurologic deficit. The treatment of multilevel spine injuries should follow the same principles as single level injury, stability and neurologic symptoms indicate the appropriate treatment.

Review article: indications for thoracolumbar imaging in blunt trauma patients: a review of current literature

Thoracolumbar spine injury is a common complication of blunt multitrauma and up to one third of fractures are associated with spinal cord dysfunction. Delayed fracture diagnosis increases the risk of neurological complications. While validated screening guidelines exist for traumatic c-spine injury equivalent guidelines for thoracolumbar screening are lacking. We conducted a literature review evaluating studies of thoracolumbar injury in trauma patients to generate indications for thoracolumbar imaging. We performed MEDLINE and Pubmed searches using MeSH terms "Wounds, Nonpenetrating", "Spinal Fractures", "Spinal Injuries" and "Diagnostic Errors", MeSH/subheading terms "Thoracic Vertebrae/injuries" and "Lumbar Vertebrae/injuries" and keyword search terms "thoracolumbar fractures", "thoracolumbar injuries", "thoracolumbar trauma", "missed diagnoses" and "delayed diagnoses". Limits and inclusion criteria were defined prior to searching. We evaluated 16 articles; 5 prospective observational studies (1 cohort study) and 11 retrospective observational studies. Predictors of TL injury in prospective studies - high-risk injury mechanism, distracting injury, impaired cognition, symptoms/signs of vertebral fracture and known cervical fracture--were defined and used to construct a decision algorithm, which in a total of 14189 trauma patients from all eligible studies recommended TL screening in 856(99.1%) of 864 patients with TL fractures and would probably have directed TL imaging in the remaining 8 patients. There is limited low level evidence guiding surveillance TL imaging in adult blunt trauma patients. Despite this, we propose and evaluate an algorithm with a high negative predictive value for TL fractures. This should be incorporated into spinal injury assessment protocols.

Complications in spine surgery

OBJECT

The overall incidence of complications or adverse events in spinal surgery is unknown. Both prospective and retrospective analyses have been performed, but the results have not been critically assessed. Procedures for different regions of the spine (cervical and thoracolumbar) and the incidence of complications for each have been reported but not compared. Authors of previous reports have concentrated on complications in terms of their incidence relevant to healthcare providers: medical versus surgical etiology and the relevance of perioperative complications to perioperative events. Few authors have assessed complication incidence from the patient's perspective. In this report the authors summarize the spine surgery complications literature and address the effect of study design on reported complication incidence.

METHODS

A systematic evidence-based review was completed to identify within the published literature complication rates in spinal surgery. The MEDLINE database was queried using the key words "spine surgery" and "complications." This initial search revealed more than 700 articles, which were further limited through an exclusion process. Each abstract was reviewed and papers were obtained. The authors gathered 105 relevant articles detailing 80 thoracolumbar and 25 cervical studies. Among the 105 articles were 84 retrospective studies and 21 prospective studies. The authors evaluated the study designs and compared cervical, thoracolumbar, prospective, and retrospective studies as well as the durations of follow-up for each study.

RESULTS

In the 105 articles reviewed, there were 79,471 patients with 13,067 reported complications for an overall complication incidence of 16.4% per patient. Complications were more common in thoracolumbar (17.8%) than cervical procedures (8.9%; p < 0.0001, OR 2.23). Prospective studies yielded a higher incidence of complications (19.9%) than retrospective studies (16.1%; p < 0.0001, OR 1.3). The complication incidence for prospective thoracolumbar studies (20.4%) was greater than that for retrospective series (17.5%; p < 0.0001). This difference between prospective and retrospective reviews was not found in the cervical studies. The year of study publication did not correlate with the complication incidence, although the duration of follow-up did correlate with the complication incidence (p = 0.001).

CONCLUSIONS

Retrospective reviews significantly underestimate the overall incidence of complications in spine surgery. This analysis is the first to critically assess differing complication incidences reported in prospective and retrospective cervical and thoracolumbar spine surgery studies.

The beneficial effects of early stabilization of thoracic spine fractures depend on trauma severity

BACKGROUND

The timing of stabilization for thoracic spine injuries is discussed controversial. Although early repair of long bone fractures is known to reduce complications, few studies investigate this issue in spine trauma.

METHODS

We retrospectively investigated 160 patients (January 2000 to March 2003) with spine fractures from Th1 to L1, which were stabilized. Patients were divided into two groups: early stabilization within 72 hours or later. Other subgroups were analyzed for the relationship of neurologic status, injury severity, and incidence of preoperative lung failure.

RESULTS

: Severely injured patients (Injury Severity Score >or=38 pts) with early stabilization had a significantly shorter intensive care unit-stay (14 days [1-34 days] vs. 20 days [1-39 days]; p < 0.05) and overall shorter hospital stay (56 days [9-147 days] vs. 108 days [11-198 days]; p < 0.05). Similar patterns were seen for patients with Frankel A deficits (Frankel Score) and preoperative lung failure. The clinical course of less severe-injured patients was not influenced at all.

CONCLUSIONS

Our data provide further evidence that early stabilization of spine injuries is safe. In severely injured patients, it does not impair perioperative lung function and results in a reduced overall intensive care unit and hospital stay.

Laminar fractures as a severity marker in burst fractures of the thoracolumbar spine

PURPOSE

To assess the correlation between the presence of lamina fractures, narrowing of the spinal canal, and the severity of injury.

METHODS

Records of 146 men and 44 women aged 13 to 84 (mean, 39) years diagnosed with burst fractures of the thoracolumbar spine were retrospectively reviewed. The laminar fractures and narrowing of the spinal canal were measured using computed tomography. The severity of injury was determined using the Injury Severity Score (ISS) and the New Injury Severity Score (NISS). The ISS and NISS of patients with and without laminar fractures were compared. The sensitivity and specificity of ISS, NISS, and narrowing of the spinal canal in association with laminar fractures were also compared.

RESULTS

92 (48%) of the patients had laminar fractures. The mean narrowing of the spinal canal was more severe in patients with laminar fractures than those without (47% vs 28%, p<0.001). Patients with laminar fractures had a significantly higher mean ISS (17 vs 12, p<0.001) and NISS (19 vs 13, p<0.001). Narrowing of the spinal canal is more sensitive and specific than the ISS and NISS when correlating laminar fractures.

CONCLUSION

In patients with burst fractures of the thoracolumbar spine, the presence of laminar fractures indicates a more severe injury.