Management of thoracolumbar spine trauma: An overview

Comparison of Wiltse Approach of Pedicle Screw Fixation With or Without Vertebroplasty in the Treatment of Genant III Degree Osteoporotic Thoracolumbar Fractures: Analysis of Clinical Findings, Radiographic Parameters, and Follow-Up Complications

STUDY DESIGN

A retrospective case-control study.

OBJECTIVE

This study aimed to compare the effects of the Wiltse approach of pedicle screw fixation (PSF) either in combination with or without vertebroplasty (VP) in the treatment of Genant III degree osteoporotic thoracolumbar fractures (Genant III-OTLFs).

METHODS

A retrospective study of Genant III-OTLFs was performed from January 2018 to December 2019, including 54 cases of PSF + VP and 56 cases of PSF. Clinical indicators [visual analog scale (VAS) score, Oswestry disability index (ODI)], radiographic parameters [local kyphosis angle (LKA), percentage of anterior, central, and posterior vertebral heights (AVH%, CVH%, and PVH%, respectively)] and follow-up complications [adjacent vertebral fracture (AVF), residual pain (RP), vertebral height loss (VHL), and internal fixation failure (IFF)] were compared between the 2 groups.

RESULTS

No differences in surgical outcomes, clinical indicators, and radiographic parameters were observed between the 2 groups during the preoperation period and 7 days post-operatively (P > .05). However, the VAS score [2.0 (.6), 1.9 (.5)], ODI [23.7 (4.0), 22.6 (3.0)], LKA [9.5 (1.8), 10.6 (3.0)], AVH% [90.1 (2.7), 87.7 (6.0)], CVH% [92.5 (2.6), 91.3 (3.7)], and PVH% [93.4 (2.0), 92.7 (2.4)] at 1 year post-operatively and last follow-up of the PSF + VP group were better than those of the PSF group [2.5 (.8), 3.1 (1.1), 26.6 (3.8), 29.6 (4.6), 12.2 (1.6), 16.6 (3.2), 84.9 (4.0), 69.9 (6.6), 88.1 (3.1), 78.2 (5.1), 89.7 (2.3), 84.8 (4.6)], respectively (P < .001). During follow-up, the incidence of AVF had no difference (P > .05), while that of RP (32.1 vs 14.8%), VHL (33.9 vs 9.3%) and IFF (17.9 vs 5.6%) had statistical differences between them (P < .05).

CONCLUSION

The Wiltse approach of PSF combined with VP for Genant III-OTLFs can not only effectively relieve pain, restore vertebral height, and correcte kyphosis, but also better maintain vertebral height, delay kyphosis progression, and reduce complications during follow-up.

A4 Thoracolumbar Fracture Class Is Associated With a Greater Degree of Vertebral Height Loss in Conservatively Managed Patients

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.

Modified 5-Item Frailty Index: A Useful Tool for Assessing the Impact of Frailty on Postoperative Morbidity and Mortality Following Surgical Fixation of Thoracolumbar Fractures

OBJECTIVES

The modified 5-item frailty index (mFI-5) is a comorbidity-based risk stratification tool to predict adverse events following various neurologic surgeries. This study aims to quantify the association between increased mFI-5 and postoperative complications and mortality following surgical fixation of traumatic thoracolumbar fractures.

METHODS

The 2011-2021 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to identify patients undergoing fusion surgeries for thoracolumbar spine fractures. The mFI-5 score was calculated based on the presence of 5 major comorbidities: congestive heart failure within 30 days before surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, partially dependent or totally dependent functional health status at the time of surgery, and hypertension requiring medication. Multivariate analysis assessed the independent impact of increasing mFI-5 scores on postoperative 30-day morbidity and mortality while controlling for baseline clinical characteristics.

RESULTS

A total of 66,904 patients were included in our analysis (54.2% female, mean age 62.27 ± 12.93 years). On univariate analysis, higher mFI-5 score was significantly associated with increased risks of superficial surgical site infection, deep surgical site infection, wound dehiscence, unplanned reoperation, pneumonia, unplanned intubation, postoperative ventilator use, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, myocardial infarction, cardiac arrest, pulmonary embolism, deep vein thrombosis, bleeding requiring transfusion, sepsis, septic shock, and longer hospital length of stay (LOS). On multivariate logistic regression, increasing mFI-5 score versus a mFI-5 score of zero was associated with higher odds of overall complications (mFI-5 ≥2: odds ratio [OR] 1.38 CI: 1.24-1.54, P < 0.001; mFI-5 = 1: OR 1.18 CI: 1.11-1.24, P < 0.001) and 30-day mortality (mFI-5 ≥2: OR 2.33 CI: 1.60-3.38, P < 0.001).

CONCLUSION

This study demonstrates that frailty, when measured using the mFI-5, independently predicts postoperative complications, hospital LOS, and 30-day mortality after surgical repair of thoracolumbar fractures. These findings are important for risk stratification in patients undergoing thoracolumbar fusion surgery and for standardization in reporting outcomes after those procedures.

Thoracolumbar Fractures: Comparing the Effect of Minimally Invasive Versus Open Schanz Screw Techniques on Sagittal Alignment

STUDY DESIGN

This is a retrospective comparative cohort study.

PURPOSE

This study aims to compare the effects of minimally invasive surgery (MIS) and open surgery (OS) on global sagittal alignment (GSA) in surgically managed thoracolumbar fractures.

OVERVIEW OF LITERATURE

The optimal treatment of traumatic thoracolumbar fractures (TLF) remains controversial. Both MIS techniques with polyaxial screws and OS techniques with Schanz screws have gained widespread use. The effect of each technique on the global sagittal alignment has not been reported.

METHODS

From 2014 to 2021, 22 patients with traumatic TLF underwent open posterior stabilization using an open transpedicular Schanz screw-rod construct and were compared to 15 patients who underwent minimally invasive surgery using a polyaxial percutaneous pedicle screw-rod construct. The reported radiological parameters measured on preoperative supine CT scan and immediate postop standing X-ray and on final follow-up whole spine standing X-rays included pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), preoperative segmental kyphosis (Preop-K), immediate post-operative segmental kyphosis (postop-Ki), final post-operative segmental kyphosis (postop-Kf), sagittal-vertica-axis (SVA), and spino-sacral angle (SSA).

RESULTS

The average age of the OS group was 42.5 years; 5 patients had AO type B, and 17 patients had AO type A (A3 and A4) fractures. The average follow-up was 16.8 months. The average radiological parameters were: PI = 54.9°, PI-LL = 3°, PT = 17.6°, preop-K = 16.2°, postop-Ki = 8.7°, final postop-Kf = 14.3°, SVA = 4.58 cm, and SSA = 101.8°. The average age of the MIS group was 43.4 years; 5 patients had AO type B, and 10 patients had AO type A fractures. The average follow-up was 25 months. The average radiological parameters were as follows: PI = 51°, PI-LL = 8°, PT = 18°, preop-K = 18.4°, postop-Ki = 11.6°, postop-Kf = 14.3°, SVA = 6.4 cm, SSA = 106°.

CONCLUSION

The fixation technique did not significantly affect the final correction of the local kyphosis and global spine alignment parameters.

Presentation, Management, and Outcomes of Thoracic, Thoracolumbar, and Lumbar Spine Trauma in East Africa: A Cohort Study

BACKGROUND

Trauma to the thoracic, thoracolumbar (TL), and lumbar spine is common and can cause disability and neurological deficits. Using a cohort of patients suffering from thoracic, TL, and lumbar spine trauma in a tertiary hospital in East Africa, the current study sought to: (1) describe demographics and operative treatment patterns, (2) assess neurologic outcomes, and (3) report predictors associated with undergoing surgery, neurologic improvement, and mortality.

METHODS

A retrospective cohort study of patient records from September 2016 to December 2020 was conducted at a prominent East Africa referral center. The study collected data on demographics, injury, and operative characteristics. Surgical indications were assessed using the AO (Arbeitsgemeinschaft für Osteosynthesefragen) TL fracture classification system and neurological function. Logistic regression analysis identified predictors for operative treatment, neurologic improvement, and mortality.

RESULTS

The study showed that 64.9% of the 257 TL spine trauma patients underwent surgery with a median postadmission day of 17.0. The mortality rate was 1.2%. Road traffic accidents caused 43.6% of the injuries. The most common fracture pattern was AO Type A fractures (78.6%). Laminectomy and posterolateral fusion were performed in 97.6% of the surgical cases. Patients without neurological deficits (OR: 0.27, 95% CI: 0.13-0.54, P < 0.001) and those with longer delays from injury to admission were less likely to have surgery (OR: 0.95, 95% CI: 0.92-0.99, P = 0.007). The neurologic improvement rate was 11.1%. Univariate analysis showed a significant association between surgery and neurologic improvement (OR: 3.83, 95% CI: 1.27-16.61, P < 0.001). However, this finding was lost in multivariate regression.

CONCLUSIONS

This study highlights various themes surrounding the management of TL spine trauma in a low-resource environment, including lower surgery rates, delays from admission to surgery, safe surgery with low mortality, and the potential for surgery to lead to neurologic improvement.

CLINICAL RELEVANCE

Despite challenges such as surgical delays and limited resources in East Africa, there is potential for surgical intervention to improve neurologic outcomes in thoracic, TL, and lumbar spine trauma patients.

LEVEL OF EVIDENCE: 4

[Effectiveness of injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion for thoracolumbar fracture dislocation with disc injury]

Objective

To investigate the effectiveness of injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion for thoracolumbar fracture dislocation with disc injury.

Methods

Between January 2017 and June 2022, 28 patients with thoracolumbar fracture dislocation with disc injury were underwent posterior depression, the injured vertebra fixation with inclined-long pedicle screws, and interbody fusion. There were 22 males and 6 females, with a mean age of 41.4 years (range, 22-58 years). The causes of injury included falling from height in 18 cases, traffic accident in 5 cases, and bruise in 5 cases. Fracture segment included 1 case of T 11, 7 cases of T 12, 9 cases of L 1, and 11 cases of L 2. According to the American Spinal Injury Association (ASIA) scale, the spinal injuries were graded as grade A in 4 cases, grade B in 2 cases, grade C in 11 cases, and grade D in 11 cases. Preoperative spinal canal encroachment ratio was 17.7%-75.3% (mean, 44.0%); the thoracolumbar injury classification and severity score (TLICS) ranged from 9 to 10 (mean, 9.9). Seventeen patients were associated with other injuries. The time from injury to operation ranged from 1 to 4 days (mean, 2.3 days). The perioperative indicators (operation time, intraoperative blood loss, and the occurrence of complications), clinical evaluation indicators [visual analogue scale (VAS) score and Oswestry Disability Index (ODI)], radiologic evaluation indicators [anterior vertebral height ratio (AVHR), kyphosis Cobb angle (KCA), intervertebral space height (ISH), vertebral wedge angle (VWA), displacement angle (DA), and percent fracture dislocation displacement (PFDD)], neurological function, and interbody fusion were recorded.

Results

The operation time was 110-159 minutes (mean, 130.2 minutes). The intraoperative blood loss was 200-510 mL (mean, 354.3 mL). All incisions healed by first intention, and no surgical complications such as wound infection or hematoma occurred. All patients were followed up 12-15 months (mean, 12.7 months). The chest and lumbar pain significantly relieved, VAS scores and ODI after operation were significantly lower than those before operation, and further decreased with the extension of postoperative time, with significant differences ( P<0.05). At last follow-up, the ASIA classification of neurological function of the patients was grade A in 3 cases, grade B in 1 case, grade C in 1 case, grade D in 10 cases, and grade E in 13 cases, which was significantly different from preoperative one ( Z=-4.772, P<0.001). Imaging review showed that AVHR, KCA, ISH, VWA, DA, and PFDD significantly improved at 1 week, 3 months and last follow-up ( P<0.05). There was no significant difference between different time points after operation ( P>0.05). At last follow-up, according to the modified Brantigan score, all patients achieved good intervertebral bone fusion, including 22 complete fusion and 6 good intervertebral fusion with a few clear lines. No complications such as internal fixation failure or kyphosis occurred during follow-up.

Conclusion

The injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion is an effective treatment for thoracolumbar fracture dislocation with disc injury, which can correct the fracture dislocation, release the nerve compression, restore the injured vertebral height, and reconstruct spinal stabilization.

Subject-Specific Geometry of FE Lumbar Spine Models for the Replication of Fracture Locations Using Dynamic Drop Tests

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.

Thoracic and Lumbar Spine Injury: Evidence-Based Diagnosis, Management, and Outcomes

BACKGROUND

Traumatic thoracolumbar spine injuries are associated with significant morbidity and mortality. Targeted for non-spine specialist trauma surgeons, this systematic scoping review aimed to examine literature for up-to-date evidence on presentation, management, and outcomes of thoracolumbar spine injuries in adult trauma patients.

METHODS

This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched four bibliographic databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. Eligible studies included experimental, observational, and evidence-synthesis articles evaluating patients with thoracic, lumbar, or thoracolumbar spine injury, published in English between January 1, 2010 and January 31, 2021. Studies which focused on animals, cadavers, cohorts with N <30, and pediatric cohorts (age <18 years old), as well as case studies, abstracts, and commentaries were excluded.

RESULTS

A total of 2501 studies were screened, of which 326 unique studies were fully text reviewed and twelve aspects of injury management were identified and discussed: injury patterns, determination of injury status and imaging options, considerations in management, and patient quality of life. We found: (1) imaging is a necessary diagnostic tool, (2) no consensus exists for preferred injury characterization scoring systems, (3) operative management should be considered for unstable fractures, decompression, and deformity, and (4) certain patients experience significant burden following injury.

DISCUSSION

In this systematic scoping review, we present the most up-to-date information regarding the management of traumatic thoracolumbar spine injuries. This allows non-specialist trauma surgeons to become more familiar with thoracolumbar spine injuries in trauma patients and provides a framework for their management.

Percutaneous reduction of thoracolumbar fractures using monoaxial screws: Comparison of two instruments based on initial reduction and loss of reduction

Introduction

Percutaneous techniques for the surgical treatment of vertebral fractures are constantly progressing. There are different biomechanics involved.

Research question

Two percutaneous, monoaxial fixation systems with different reduction tools were analyzed in relation to their reduction capacity. Additionally, the impact of anterior fusion, fracture severity and bone quality on reduction and loss of reduction were examined.

Material and methods

117 cases were retrospectively included in the monocentric study. The subsample (N = 53) with complete data at follow-up times was used to analyze the influence of anterior fusion. The dependencies on fracture severity and bone quality were determined using Spearman and Pearson correlation.

Results

Both systems achieved equally good reduction (9° mean, 95%-CI: 8°-11°, p < 0.001). Anterior fused patients showed not significant (p = 0.057) less loss of reduction over time. Fracture severity had neither an influence on reduction or loss of reduction. Bone quality was positively correlated with greater amount of reduction and less loss of reduction. Early reduction within two days correlated with a greater amount of reduction (p = 0.006). Screw diameters and the patient's weight had no influence on loss of reduction. Complications occurred only in "V2" group.

Discussion and conclusion

Both systems are equivalent in reduction ability. The additional anterior fusion did not result in significantly lower reduction losses. The subsample being small, is a limitation. Good bone quality correlates with better initial reduction and less reduction loss. A preoperative bone density measurement can lead to optimization of surgical techniques.

Finite element analysis of different pedicle screw internal fixations for first lumbar vertebral fracture in different sports conditions

OBJECTIVE

Lumbar fractures are the most common spinal injuries, and surgery is required for severe fracture. This study aimed to investigate the variations in motion and stress in varying states of activity after minimally invasive and traditional open pedicle screw placement for L1 vertebral fracture stabilization.

METHODS

We studied a male volunteer (26 years old) with no history of chronic back pain or lumbar spine trauma. We used the finite element method for this investigation. Using finite element software, we created a three-dimensional model of L1 vertebral compression fracture. We also constructed models for four percutaneous pedicle screws spanning the fractured vertebra and four screws traversing the damaged vertebra with transverse fixation.

RESULTS

In all three-dimensional movement directions, the open pedicle fixation system experienced maximum stress higher than its percutaneous counterpart. With axial spinal rotation, von Mises stress on the traditional open pedicle screw was considerably lower than that with percutaneous pedicle fixation, but peak stress was elevated at the transverse connection. Traditional open pedicle fixation displayed less maximum displacement than percutaneous pedicle internal fixation.

CONCLUSIONS

During axial spinal movements, high peak stress is observed at the transverse connection. Patients should avoid excessive axial rotation of the spine during recovery.

The AO Spine Thoracolumbar Injury Classification System and Treatment Algorithm in Decision Making for Thoracolumbar Burst Fractures Without Neurologic Deficit

STUDY DESIGN

Prospective Observational Study.

OBJECTIVE

To determine the alignment of the AO Spine Thoracolumbar Injury Classification system and treatment algorithm with contemporary surgical decision making.

METHODS

183 cases of thoracolumbar burst fractures were reviewed by 22 AO Spine Knowledge Forum Trauma experts. These experienced clinicians classified the fracture morphology, integrity of the posterior ligamentous complex and degree of comminution. Management recommendations were collected.

RESULTS

There was a statistically significant stepwise increase in rates of operative management with escalating category of injury (P < .001). An excellent correlation existed between recommended expert management and the actual treatment of each injury category: A0/A1/A2 (OR 1.09, 95% CI 0.70-1.69, P = .71), A3/4 (OR 1.62, 95% CI 0.98-2.66, P = .58) and B1/B2/C (1.00, 95% CI 0.87-1.14, P = .99). Thoracolumbar A4 fractures were more likely to be surgically stabilized than A3 fractures (68.2% vs 30.9%, P < .001). A modifier indicating indeterminate ligamentous injury increased the rate of operative management when comparing type B and C injuries to type A3/A4 injuries (OR 39.19, 95% CI 20.84-73.69, P < .01 vs OR 27.72, 95% CI 14.68-52.33, P < .01).

CONCLUSIONS

The AO Spine Thoracolumbar Injury Classification system introduces fracture morphology in a rational and hierarchical manner of escalating severity. Thoracolumbar A4 complete burst fractures were more likely to be operatively managed than A3 fractures. Flexion-distraction type B injuries and translational type C injuries were much more likely to have surgery recommended than type A fractures regardless of the M1 modifier. A suspected posterior ligamentous injury increased the likelihood of surgeons favoring surgical stabilization.

Intraoperative Closed Reduction of Traumatic Lateraloptosis: Operative Nuances

BACKGROUND AND IMPORTANCE

Traumatic lateral spondyloptosis, or lateraloptosis, is the complete lateral dislocation of the spine. Reduction in these dislocations presents unique challenges, especially in cases of preserved neurological function. Open techniques carry significant risks of cerebrospinal fluid leak and neurological injury. For traditional spondyloptosis, off-table closed techniques have been described but may result in loss of the reduction when the patient is transferred to the operative table. An on-table closed reduction technique has potential advantages over previously described open reduction or off-table techniques for the treatment of lateraloptosis.

CLINICAL PRESENTATION

The authors describe an on-table closed reduction technique for lateraloptosis, presenting an illustrative case in which the technique was applied. This technique is compared with alternative open and off-table reduction techniques described in the literature. The patient had good mechanical and neurological outcomes. At 14 months postoperatively, she is neurologically intact, back to work involving heavy lifting, and has only moderate back pain.

CONCLUSION

On-table closed reduction before open fixation should be considered in cases of lateraloptosis, particularly when there is preserved neurological function.

Deep learning system for automated detection of posterior ligamentous complex injury in patients with thoracolumbar fracture on MRI

This study aimed to develop a deep learning (DL) algorithm for automated detection and localization of posterior ligamentous complex (PLC) injury in patients with acute thoracolumbar (TL) fracture on magnetic resonance imaging (MRI) and evaluate its diagnostic performance. In this retrospective multicenter study, using midline sagittal T2-weighted image with fracture (± PLC injury), a training dataset and internal and external validation sets of 300, 100, and 100 patients, were constructed with equal numbers of injured and normal PLCs. The DL algorithm was developed through two steps (Attention U-net and Inception-ResNet-V2). We evaluate the diagnostic performance for PLC injury between the DL algorithm and radiologists with different levels of experience. The area under the curves (AUCs) generated by the DL algorithm were 0.928, 0.916 for internal and external validations, and by two radiologists for observer performance test were 0.930, 0.830, respectively. Although no significant difference was found in diagnosing PLC injury between the DL algorithm and radiologists, the DL algorithm exhibited a trend of higher AUC than the radiology trainee. Notably, the radiology trainee's diagnostic performance significantly improved with DL algorithm assistance. Therefore, the DL algorithm exhibited high diagnostic performance in detecting PLC injuries in acute TL fractures.

Clinic choice of long or short segment pedicle screw-rod fixation in the treatment of thoracolumbar burst fracture: From scan data to numerical study

Based on computerized tomography scanning images of human lumbar vertebrae, finite element (FE) analysis is performed to predict the stress of pedicle screws, rods, and fractured vertebra as well as the displacement of fractured vertebra after internal fixation treatment of thoracolumbar burst fracture. A three-dimensional FE model of L1-L5 lumbar vertebrae with L3 burst fracture has been established and four fixation methods, namely, short segment cross- and trans-injured vertebrae, long segment cross- and trans-injured vertebrae fixations, have been adopted to perform posterior pedicle fixation. The stress distributions of the screws, rods, and fractured vertebra and the total deformation of the fractured vertebra are investigated under six different physiological motions. From the view of the stress on the screw-rod system and the deformation of the fractured vertebral body, the long segment cross-injured vertebra fixation has the best mechanical performance, followed by the long segment trans-injured vertebra fixation, and then the short segment fixation trans-injured vertebra. The short segment fixation cross-injured vertebra performs the worst. Among the six motions, the forward flexion movement has the greatest impact on the screw-rod system and the fractured vertebra. However, the rotation motion greatly affects the stress of the screw in the long segment fixation. This indicates that the longer the fixed segment is, the more susceptible it is to human rotation. Thus, for patients with severe fracture, the long segment cross-injured vertebra is preferred. On the contrary, the short segment trans-injured vertebra fixation is optimal.

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

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

Comparison of clinical effects of percutaneous vertebroplasty with two different puncture approaches on the treatment of thoracolumbar osteoporotic vertebral compression fractures with narrow pedicles: a retrospective controlled study

PURPOSE

To evaluate the effects of percutaneous vertebroplasty (PVP) with conventional transpedicle approach (CTA) or basal transverse process-pedicle approach (BTPA) on the treatment of thoracolumbar osteoporotic vertebral compression fractures (TL-OVCFs) with narrow pedicles.

METHODS

A retrospective study of TL-OVCFs with narrow pedicles was performed, including 78 cases of CTA and 84 cases of BTPA. The surgical outcomes, radiographic parameters [the width and height of the pedicle (PW, PH), the inclination angle of puncture (PIA)] and clinical indicators [visual analog scale (VAS) score, Oswestry Disability Index (ODI)] of two groups were compared.

RESULTS

In terms of surgical outcomes of them, there was no difference in operation time (P > 0.05), while the volume of bone cement, the incidence of bone cement leakage and rate of good bone cement distribution were significantly worse in the CTA group (4.4 ± 0.6 ml vs. 5.5 ± 0.5 ml, 37.2% vs. 20.2%, 52.6% vs. 79.8%, P < 0.05). As for radiographic parameters and clinical indicators of them, the differences were not observed in the PH, PW, preoperative VAS score and ODI (P > 0.05), whereas the PIA, VAS score and ODI at 1 day postoperatively were significantly better in the BTPA group (17.3 ± 2.1° vs. 29.6 ± 2.8°, 2.7 ± 0.7 vs. 2.1 ± 0.8, 32.8 ± 4.6 vs. 26.7 ± 4.0, P < 0.05).

CONCLUSION

The study provided solid evidence that PVP with BTPA had more advantages in the treatment of TL-OVCFs with narrow pedicles, which can better relieve postoperative pain.

Finite element analysis of minimally invasive nail placement and traditional nail placement in the treatment of lumbar 1 vertebral compression fracture

Using the finite element analysis method to help us better understand the biomechanical changes of the spine after surgery and the changes in the stress distribution around the screw implantation area. The finite element model of L1 vertebral compression fracture was constructed by using a large number of finite element programs. On the fracture model, 2 kinds of internal fixation devices are set up, namely: the first type of 4 screws across the injured vertebra through the adjacent upper and lower vertebrae + transverse connector; the second type of 4 screws crosses the injured vertebra through the adjacent upper and lower vertebrae + non-transverse connector. To study the distribution of the maximum displacement and von Mises stress of the intramedullary pedicle screws and rods of the 2 types of internal fixation devices after implantation in the spine under certain loading conditions. In traditional open pedicle screw fixation, the maximum stress in the pedicle screw fixation system in the direction of 3D movement is higher than in percutaneous pedicle screw fixation. There is no significant difference in the Von Mises stress of the pedicle screw between the 2 procedures when the spine performs flexion-extension and lateral flexion activities. When the spine is rotating axially, the Von Mises stress of the pedicle screw in conventional open surgery is significantly less than that of the screw in percutaneous pedicle screw fixation. Traditional open internal fixation produces stress peaks of 891.7 MPa and 886.34 MPa at the transverse joint during axial rotation. Only when the spine is rotating in the axial direction, the maximum displacement of traditional open pedicle screw fixation is smaller than that of percutaneous pedicle screw fixation. There is no significant difference in the maximum displacement between the 2 procedures when the spine is moving in other directions. Traditional open pedicle screw fixation can strengthen the stability of the spine in the direction of axial rotation, and can also be greater to reduce the maximum stress of the pedicle screw axial rotation, so the clinical treatment of unstable fractures of the thoracolumbar spine instability is of great significance.

Patient-reported outcomes after posterior surgical stabilization for thoracolumbar junction fractures: A pilot study with combined patient-reported outcome measure methodology

Background

Thoracolumbar junction fractures (TLJFs) attract controversy for several parameters, including surgery versus conservative treatment, fusion versus stabilization, open versus percutaneous surgery, construct length, and downstream metalwork extraction.

Aims and Objectives

The aim of this pilot study was to assess the effectiveness of surgical treatment in patients with burst (AO Classification Type A4) TLJFs using patient-reported outcome measures (PROMs) and evaluate and compare different PROMs in this clinical scenario.

Materials and Methods

Patient records of consecutive patients who underwent posterior stabilization surgery for TLJFs were retrospectively reviewed. Data were collected on demographics, medical and social history, neurological examination, and postoperative complications. Telephone interviews and a combined PROM methodology (Numerical Rating Scale [NRS], EuroQol [EQ]-5D-5L, and Oswestry Disability Index [ODI]) were utilized to assess the effectiveness of intervention. Descriptive statistics were used to analyze exposure variables and outcome measures. Spearman's rank correlation was used for the outcome measures.

Results

Thirteen patients were included. The mean age was 42 ± 16 years; the male: female ratio was 8:5; the mean follow-up was 18.9 ± 6.4 months. The mean NRS score was 3.3 ± 2.5, in line with a median score of 2 (2) on EQ-5D-5L pain/discomfort scale. Statistically significant correlations were found between several PROMs: pain-EQ-5D-5L and NRS (rs = 0.8, P = 0.002), pain-EQ-5D-5L and ODI (rs = 0.8, P = 0.001), usual anxiety/depression-EQ-5D-5L, and ODI (rs = 0.7, P = 0.008).

Conclusion

A combined PROM methodology showed supportive evidence for safety and efficacy in the surgical stabilization of burst TLJFs. This alleviated significant pain and prevented neurological deficit and major disability. The preliminary widespread correlation between these PROMs supports further larger studies of their combined use in clinical practice, to measure the outcomes of spine trauma patients.

A comparative study of robot-assisted and traditional surgeries in the treatment of thoracolumbar fractures based on 1-year follow-up observation

BACKGROUND: There are conflicting results for robot-assisted (RA) pedicle screw fixation compared with freehand (FH) pedicle screw fixation. OBJECTIVE: This study was designed to retrospectively compare the accuracy and efficacy of RA percutaneous pedicle screw fixation and traditional freehand FH pedicle screw fixation in the treatment of thoracolumbar fractures. METHODS: A total of 26 cases were assigned to the RA group, and 24 cases were assigned to the FH group. The operation time, bleeding volume, and visual analog scale (VAS) score 1 day after the operation, and the anterior/posterior (A/P) vertebral height ratio of the injured vertebrae at 3 days and at internal fixation removal 1 year after the operation were compared between the two groups. Pedicle screw position accuracy was assessed according to Gertzbein criteria. RESULTS: The operation times of the RA group and FH group were 138.69 ± 32.67 minutes and 103.67 ± 14.53 minutes, respectively, and the difference was statistically significant. The intraoperative blood loss was 49.23 ± 22.56 ml in the RA group and 78.33 ± 23.90 ml in the FH group, and the difference was statistically significant. There was a significant difference in the A/P vertebral height ratio of the injured vertebrae 3 days after the operation compared with before the operation in both groups (P < 0.05). There was a significant difference in the A/P vertebral height ratio of the injured vertebrae 3 days after the operation compared with that at fixation removal in both groups (P < 0.05). CONCLUSION: The application of RA orthopedic treatment for thoracolumbar fractures can achieve good fracture reduction.

Immediate standing X-ray predicts the final vertebral collapse in elderly patients with thoracolumbar burst fracture

OBJECTIVE

To see if, in elderly patients with traumatic thoracolumbar fracture, standing X-rays with orthoses 24-48h after admission can predict vertebral collapse after consolidation.

MATERIAL AND METHODS

Prospective cohort study endorsed by the Clinical Research Ethics Committee.

INCLUSION CRITERIA

age >65 years, acute thoracolumbar junction fracture due to fall, hospital admission, treatment with orthesis.

EXCLUSION CRITERIA

various levels, suspected malignancy, non-immediate fracture or atraumatic.

VARIABLES

Farcy index (F), regional kyphosis (C: Cobb from cranial to caudal to broken vertebra) - both measured at admission (F0 and C0), at 24-48h in standing position with orthesis (F1 and C1) and 3 months, without brace (F2 and C2), collapse (increase from F0 to F1 -F0F1- and from F1 to F2 -F1F2-; as well as from C0 to C1 -C0C1- and from C1 to C2 -C1C2-), age and gender.

STATISTICAL ANALYSIS

R package.

RESULTS

Series of 40 patients, with a mean age of 75 years (66-87). Nine men and 31 women. Neither gender nor age were correlated with any variable. Six required surgery at follow-up. There were no differences in F1, C1, F0F1 or C0C1 between the six patients who required surgery and the other 34. Subsequently, data analysis was performed only for those patients who did not require surgery. The values obtained in the Farcy index were 8°+7° (F0), 12°+7° (F1) and 15°+8° (F2) and in kyphosis (three vertebrae, Cobb) they were: C0=8°+13°; C1=11.5°+14° and C2=13°+13°. There was a correlation of F2 with F0 and F1 (p<.001), with F0F1 (p=.038) and F1F2 (p=.007). The most powerful was with F1 (Rho Spearman=.889 (95% CI=.776-.947), with a Linear Regression line: F2=2.61288+F1×1.01237 (R²=.79). C2 was correlated with C0 and C1 (p<.001), especially with C1 (Rho Spearman=.952, 95% CI=.899-.977). Linear regression: C2=2.23371+C1×0.93758 (R²=.927).

CONCLUSIONS

Immediate standing collapse predicts alignment at consolidation (3 months). It is therefore advisable to perform that radiography in the follow-up protocol.

[Translated article] Immediate standing X-ray predicts the final vertebral collapse in elderly patients with thoracolumbar burst fracture

OBJECTIVE

To see if, in elderly patients with traumatic thoracolumbar fracture, standing X-rays with orthoses 24-48h after admission can predict vertebral collapse after consolidation.

MATERIAL AND METHODS

Prospective cohort study endorsed by the Clinical Research Ethics Committee.

INCLUSION CRITERIA

age >65 years, acute thoracolumbar junction fracture due to fall, hospital admission, treatment with orthesis.

EXCLUSION CRITERIA

various levels, suspected malignancy, non-immediate fracture or atraumatic.

VARIABLES

Farcy index (F), regional kyphosis (C: Cobb from cranial to caudal to broken vertebra) - both measured at admission (F0 and C0), at 24-48h in standing position with orthesis (F1 and C1) and 3 months, without brace (F2 and C2), collapse (increase from F0 to F1 -F0F1- and from F1 to F2 -F1F2-; as well as from C0 to C1 -C0C1- and from C1 to C2 -C1C2-), age and gender.

STATISTICAL ANALYSIS

R package.

RESULTS

Series of 40 patients, with a mean age of 75 years (66-87). Nine men and 31 women. Neither gender nor age were correlated with any variable. Six required surgery at follow-up. There were no differences in F1, C1, F0F1 or C0C1 between the six patients who required surgery and the other 34. Subsequently, data analysis was performed only for those patients who did not require surgery. The values obtained in the Farcy index were 8°+7° (F0), 12°+7° (F1) and 15°+8° (F2) and in kyphosis (three vertebrae, Cobb) they were: C0=8°+13°; C1=11.5°+14° and C2=13°+13°. There was a correlation of F2 with F0 and F1 (p<.001), with F0F1 (p=.038) and F1F2 (p=.007). The most powerful was with F1 (Rho Spearman=.889, 95% CI=.776-.947), with a linear regression line: F2=2.61288+F1×1.01237 (R²=.79). C2 was correlated with C0 and C1 (p<.001), especially with C1 (Rho Spearman=.952, 95% CI=.899-.977). Linear regression: C2=2.23371+C1×0.93758 (R²=.927).

CONCLUSIONS

Immediate standing collapse predicts alignment at consolidation (3 months). It is therefore advisable to perform that radiography in the follow-up protocol.

The value of magnetic resonance imaging and computed tomography in the study of spinal disorders

Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.

Automated prediction of the Thoracolumbar Injury Classification and Severity Score from CT using a novel deep learning algorithm

OBJECTIVE

Damage to the thoracolumbar spine can confer significant morbidity and mortality. The Thoracolumbar Injury Classification and Severity Score (TLICS) is used to categorize injuries and determine patients at risk of spinal instability for whom surgical intervention is warranted. However, calculating this score can constitute a bottleneck in triaging and treating patients, as it relies on multiple imaging studies and a neurological examination. Therefore, the authors sought to develop and validate a deep learning model that can automatically categorize vertebral morphology and determine posterior ligamentous complex (PLC) integrity, two critical features of TLICS, using only CT scans.

METHODS

All patients who underwent neurosurgical consultation for traumatic spine injury or degenerative pathology resulting in spine injury at a single tertiary center from January 2018 to December 2019 were retrospectively evaluated for inclusion. The morphology of injury and integrity of the PLC were categorized on CT scans. A state-of-the-art object detection region-based convolutional neural network (R-CNN), Faster R-CNN, was leveraged to predict both vertebral locations and the corresponding TLICS. The network was trained with patient CT scans, manually labeled vertebral bounding boxes, TLICS morphology, and PLC annotations, thus allowing the model to output the location of vertebrae, categorize their morphology, and determine the status of PLC integrity.

RESULTS

A total of 111 patients were included (mean ± SD age 62 ± 20 years) with a total of 129 separate injury classifications. Vertebral localization and PLC integrity classification achieved Dice scores of 0.92 and 0.88, respectively. Binary classification between noninjured and injured morphological scores demonstrated 95.1% accuracy. TLICS morphology accuracy, the true positive rate, and positive injury mismatch classification rate were 86.3%, 76.2%, and 22.7%, respectively. Classification accuracy between no injury and suspected PLC injury was 86.8%, while true positive, false negative, and false positive rates were 90.0%, 10.0%, and 21.8%, respectively.

CONCLUSIONS

In this study, the authors demonstrate a novel deep learning method to automatically predict injury morphology and PLC disruption with high accuracy. This model may streamline and improve diagnostic decision support for patients with thoracolumbar spinal trauma.

Floating Thoracic Spine Due to Noncontiguous Fracture-Dislocations of the Thoracolumbar Spine

The thoracolumbar spine is the most commonly afflicted area in vertebral column injuries. Here we bring up a case of a 20-year-old male who presented to our emergency department with a history of a high-velocity road traffic accident with noncontiguous two-level fracture-dislocations of the thoracolumbar spine with blunt trauma to the chest. The patient was managed with posterior reduction and instrumented postero-lateral fusion. Such an injury pattern has been reported only rarely in the literature. This report expects to highlight the unusual fracture pattern of a common injury and the challenges of managing such severe injuries intra-operatively and in the post-operative period.

Etiologies, incidence, and demographics of lumbar vertebral fractures in U.S. emergency departments

Background

Lumbar vertebral fractures are debilitating injuries widely associated with significant patient deformity, disability, pain, and potentially neurological deficit. This cross-sectional database study investigates the most frequent annual etiologies of lumbar vertebral fractures presented to emergency departments throughout the United States (U.S.) from 2010-2018.

Methods

The National Electronic Injury Surveillance System (NEISS) database was used to identify all patients who visited participating emergency departments between 2010-2018 and were diagnosed with a lumbar spine fracture. Population estimates by age (18+) were obtained from annual U.S. Census estimates and used to calculate annual incidence rates of lumbar fractures per 100,000 people.

Results

The annual incidence rate of total lumbar fractures in the U.S. increased from 14.6 to 22.5 per 100,000 people from 2010-2018 (54%). From 2010-2018, there were 382,914 [95% confidence interval (CI): 382,855-382,973] lumbar fractures in the U.S. This increased from 34,328 (95% CI: 34,277-34,379) in 2010 to 57,098 (95% CI: 57,044-57,152) in 2018 (66.3%). Men composed 40.2% and women made up 59.8% of patients. Mean patient age increased by 2.96 years from 65.5 (95% CI: 65.38-65.62) years in 2010 to 68.4 (95% CI: 68.32-68.48) years in 2018 (4.5%). From 2010-2018, floors, stairs/steps, and ladders were the most common etiologies of lumbar fractures. Estimated sum of floor-related fractures was 80,054 (95% CI: 79,986-80,122), stair/step-related fractures was 48,274 (95% CI: 48,209-48,339), and ladder-related fractures was 31,053 (95% CI: 30,987-31,119). The increase in these three etiologies accounted for 48% of the total increase of all-cause lumbar fractures between 2010 and 2018.

Conclusions

The volume of lumbar vertebral fracture has increased over the last near decade (66.3%), and approximately half (48%) of these fractures can be attributed to accidents caused by flooring, stairs/steps, and ladder-related injuries. The increasing mean patient age, as well as accidents involving ladders, were found to be statistically correlated with the rise in total lumbar fracture volume.

Comparison of Navigated Expandable Vertebral Cage with Conventional Expandable Vertebral Cage for Minimally Invasive Lumbar/Thoracolumbar Corpectomy

Background and Objectives: The thoracolumbar burst fracture is one of the most common spinal injuries. If the patient has severe symptoms, corpectomy is indicated. Currently, minimally invasive corpectomy with a navigated expandable vertebral cage is available thanks to spinal surgical technology. The aim of this study is to retrospectively compare clinical and radiographic outcomes of conventional and navigational minimally invasive corpectomy techniques. Materials and Methods: We retrospectively evaluated 21 patients who underwent thoracolumbar minimally invasive corpectomy between October 2016 and January 2021. Eleven patients had a navigated expandable cage (group N) and 10 patients had a conventional expandable cage (group C). Mean follow-up period was 31.9 months for group N and 34.7 months for group C, ranging from 12 to 42 months in both groups. Clinical and radiographic outcomes are assessed using values including visual analogue scale (VAS) for back pain and Oswestry disability index (ODI). This data was collected preoperatively and at 6, 12, and 24 months postoperatively. Results: Surgical time and intraoperative blood loss of both groups were not significantly different (234 min vs. 267 min, 656 mL vs. 786 mL). Changes in VAS and ODI were similar in both groups. However, lateral cage mal-position ratio in group N was lower than that of group C (relative risk 1.64, Odds ratio 4.5) and postoperative cage sinking was significantly lower in group N (p = 0.033). Conclusions: Clinical outcomes are not significantly different, but radiographic outcomes of lateral cage mal-position and postoperative cage sinking were significantly lower in the navigation group.

Predictors of thoracic and lumbar spine injuries in patients with TBI: A nationwide analysis

OBJECTIVE

Cervical spine injury screening is common practice for traumatic brain injury (TBI) patients. However, risk factors for concomitant thoracolumbar trauma remain unknown. We characterized epidemiology and clinical risk for concomitant thoracolumbar trauma in TBI.

METHODS

We conducted a multi-center, retrospective cohort analysis of TBI patients in the National Trauma Data Bank from 2011-2014 using multivariable logistic regression.

RESULTS

Out of 768,718 TBIs, 46,654 (6.1%) and 42,810 (5.6%) patients were diagnosed with thoracic and lumbar spine fractures, respectively. Only 11% of thoracic and 7% of lumbar spine fracture patients had an accompanying spinal cord injury at any level. The most common mechanism of injury was motor vehicle accident (67% of thoracic and 71% and lumbar fractures). Predictors for both thoracic and lumbar fractures included moderate (thoracic: OR 1.26, 95%CI 1.21-1.31; lumbar: OR 1.13, 95%CI 1.08-1.18) and severe Glasgow Coma Scale (GCS) score (OR 1.71, 95%CI 1.67-1.75; OR 1.17, 95%CI 1.13-1.20) compared to mild; epidural hematoma (OR 1.36, 95%CI 1.28-1.44; OR 1.1, 95%CI 1.04-1.19); lower extremity injury (OR 1.38, 95%CI 1.35-1.41; OR 2.50, 95%CI 2.45-2.55); upper extremity injury (OR 2.19, 95%CI 2.14-2.23; OR 1.15, 95%CI 1.13-1.18); smoking (OR 1.09, 95%CI 1.06-1.12; OR 1.12, 95%CI 1.09-1.15); and obesity (OR 1.39, 95%CI 1.34-1.45; OR 1.29, 95%CI 1.24-1.35). Thoracic injuries (OR 4.45; 95% CI 4.35-4.55) predicted lumbar fractures, while abdominal injuries (OR 2.02; 95% CI 1.97-2.07) predicted thoracic fractures.

CONCLUSIONS

We identified GCS, smoking, upper and lower extremity injuries, and obesity as common risk factors for thoracic and lumbar spinal fractures in TBI.

Classification and Radiological Diagnosis of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

The aim of this review to determine recommendations for classification and radiological diagnosis of thoracolumbar spine fractures. Recommendation was made through a literature review of the last 10 years. The statements created by the authors were discussed and voted on during 2 consensus meetings organized by the WFNS (World Federation Neurosurgical Societies) Spine Committee. The literature review was yielded 256 abstracts, of which 32 were chosen for full-text analysis. Thirteen papers evaluated the reliability of a classification system by our expert members and were also chosen in this guideline analysis. This literature review-based recommendation provides the classification and radiologic diagnosis in thoracolumbar spine fractures that can elucidate the management decision-making in clinical practice.

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.

Concomitant spine and calcaneum fractures: a possible indication of less extensive injury

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To study the incidence of concomitant calcaneum fractures in participants with traumatic spine fractures and to study the association of calcaneum injury with the mode of trauma, morphology and level of vertebral fracture and neurological status in participants with concomitant spine and calcaneum fracture.

SETTING

Central Institute of Orthopaedics, Safdarjung Hospital, New Delhi, India.

METHODS

Records of participants with traumatic spine fractures were analyzed. Participants who had calcaneum fracture confirmed on radiographs were considered to have concomitant spine and calcaneum fracture. In these participants, variables noted were age, gender, mode of trauma, level and morphology of vertebral fracture and neurological status.

RESULTS

Concomitant calcaneum fracture was present in 43 participants out of a total of 358. The lumbar spine was involved in 72.09% of participants. 46.51% of participants had complete burst type of vertebral fractures. Neurology was found to be intact in 58.13% of participants. The association of concomitant calcaneum injury with the level of spine fracture and type of fracture were found to be statistically significant (p < 0.05). In particular, the association of concomitant calcaneal fracture with intact neurology and incomplete paraplegia (ASIA B, C or D) as compared to spinal injury cases without calcaneal fractures was statistically significant (p < 0.001).

CONCLUSION

Calcaneum fractures co-exist with spine fractures in 12.01% participants. Concomitant calcaneal fracture(s) with spine trauma indicate a greater chance of incomplete injury or intact neurology possibly due to dispersion of force vectors.

Clinical and Radiological Factors Affecting Thoracolumbar Fractures Outcome: WFNS Spine Committee Recommendations

To obtain a list of recommendations about clinical and radiological factors affecting outcome in thoraco-lumbar fractures with the aim of helping spine surgeons in daily practice. A systematic literature search in PubMed and Google Scholar database was done from 2010 to 2020 on the topic "thoracolumbar fracture AND radiology AND surgical outcomes" and "thoracolumbar fracture AND radiology AND surgical outcomes." A total of 58 papers were analyzed and WFNS (World Federation of Neurosurgical Societies) Spine Committee organized 2 consensus meetings to formulate the specific recommendations the first in Peshawar in December 2019 and in a subsequent virtual meeting in June 2020 to reach an agreement. Both meetings utilized the Delphi method to analyze preliminary literature review statements based on the current evidence levels to generate recommendations through a comprehensive voting session. Eight statements were presented and reached the consensus about this topic. A variety of clinical factors is known to influence outcome of patients with thoracolumbar fractures. Some of these are well-known established factors such as blood pressure augmentation and patient age, while some are not well studied. Overall, the quality of evidence is low and we need more randomized controlled studies to validate our results. Similarly, radiological factors that can predict outcome are well stated and there is a high accordance worldwide. In reverse, still under debate is the application to choose which surgical treatment is advisable based on them.

Minimally invasive corpectomy and percutaneous transpedicular stabilization in the treatment of patients with unstable injures of the thoracolumbar spine: Results of retrospective case series

Objective:

The objective of this study was to analyze the results of surgical treatment of patients with unstable injuries of the thoracolumbar spine using simultaneous minimally invasive corpectomy and percutaneous transpedicular stabilization.

Materials and Methods:

The retrospective study included 34 patients with isolated single-level unstable injuries of the thoracolumbar spine (5 or more points according to the Thoracolumbar Injury Classification and Severity Score (TLICS), operated on from the moment of injury from 8 to 24 h using the technique of minimally invasive corpectomy and percutaneous transpedicular stabilization simultaneously. The technical features of surgery, clinical data (pain level according to the Visual Analog Scale, quality of life according to the SF-36 questionnaire, subjective satisfaction with the operation according to the MacNab scale, and the presence of complications), and instrumental data (angle of segmental kyphotic deformity and sagittal index to and after surgery). The assessment of clinical data was carried out before surgery, at discharge, after 6 months, and in the long-term period, on average, 30 months after surgery.

Results:

When evaluating the clinical data, a significant decrease in the severity of pain syndrome was found on average from 90 mm to 5.5 mm in the late follow-up (P < 0.001), as well as a significant improvement in the physical and psychological components of health according to the SF-36 questionnaire on average from 28.78 to 39.26 (P < 0.001), from 36.93 to 41.43 (P = 0.006), respectively. In the long-term period, according to the MacNab scale, the patients noted the result of the operation: excellent – 18 (52.9%), good – 13 (38.3%), and satisfactory – 3 (8.8%); no unsatisfactory results were registered. Four (11.8%) perioperative surgical complications were registered, which were successfully treated conservatively. A significant restoration of the sagittal profile with an insignificant change in blood pressure was recorded in the long-term postoperative period. An average follow-up assessment of 30 months according to the American Spinal Injury Association scale showed the presence of E and D degrees in 85.4% of patients.

Conclusion:

Minimally invasive corpectomy with percutaneous transpedicular stabilization in the treatment of patients with unstable injuries of the thoracolumbar spine can effectively eliminate kyphotic deformity and prevent the loss of its reduction with a low number of postoperative surgical complications. The technique has minimal surgical trauma with the possibility of early postoperative rehabilitation and provides a significant stable reduction in vertebrogenic pain syndrome, improvement of neurological deficits, and restoration of the quality of life of patients and in the follow-up.

Importance of neural foraminal narrowing in lumbar spine fractures of low AIS severity

OBJECTIVE

In recent years, based on injuries predicted using machine learning, there have been efforts to reduce imaging performed on trauma patients. While useful, such efforts do not incorporate results from studies investigating the pathophysiology of traumatic events. The objective of this study was to identify potentially symptomatic vertebral foramen narrowing in the presence of minor to moderate (AIS ≤ 2 levels of severity) thoracolumbar fractures sustained in motor vehicle crashes (MVCs).

METHODS

Hospital records and images of patients admitted to a Level One trauma center between the years 2014 and 2018 with the diagnosis of thoracolumbar fracture were reviewed. Spinal injuries were scored using the AIS v2015. In addition, the geometry of the neural foramina, particularly the height of the foramina and intervertebral disk at the posterior region, were measured using reconstructed sagittal computed tomography (CT) images. The criteria for foraminal narrowing were associated with <15 mm for the foraminal height and <4 mm for the height of the posterior disk.

RESULTS

24 patients with MVCs associated thoracolumbar fractures, who met both the clinical and imaging criteria for radiculopathy and foraminal narrowing without spinal cord injury, were considered for the present clinical study. 54% of the total lumbar fracture cases reported were rated as AIS 2 injuries. AIS ≥ 3 cases reported 50% narrowing of foramen, which was expected. However, it was surprising to note that the AIS 2 cases also sustained foraminal stenosis, narrowing ranging from 13% to 20%.

CONCLUSIONS

Low severity (AIS ≤ 2) injuries were often found to be associated with foraminal narrowing leading to clinical complaints. While the present clinical study cannot determine if narrowing existed prior to the trauma, they were certainly asymptomatic prior to the trauma. The present findings emphasize the need for detailed imaging in all instances of thoracolumbar trauma, as clinically significant nerve compression may occur even with modest vertebral body injury.

Thoracolumbar Spine Trauma

Thoracolumbar spine trauma can result in potentially life-threatening consequences and requires careful management to ensure good outcomes. The purpose of this chapter is to discuss the anatomy, diagnostic tools, non-operative, and operative treatments important when addressing thoracolumbar trauma.

SPINE TRAUMA EPIDEMIOLOGICAL PROFILE IN A TERTIARY NEUROSURGERY HOSPITAL IN SOUTH BRAZIL

ABSTRACT Objective The aim of this paper is to analyze the epidemiological profile of a large series of spine trauma victims in the Southernmost state of Brazil. Methods A retrospective study including spine trauma patients was performed at a tertiary hospital from January 1st, 2013 to December 31st, 2018. The variables analyzed include demographic data, information related to the trauma (etiology, trauma mechanism, type of spine injury, number of vertebrae involved, vertebral segment involved), neurological status at hospital admission (Frankel scale), treatment performed and the outcome (number of days in hospital, neurological outcome, and mortality). Results A total of 808 patients were included. The mean age was 47.9 (±19.0), and the majority were male and Caucasian. The most frequent etiology was falls from height (N=508; 62.9%) followed by traffic accidents (N=185; 22.9%). The thoracolumbar segment was the spinal segment most frequently affected, occurring in 401 (52.1%) patients, followed by the cervical, thoracic and lumbar segments. The incidence of SCI was 16.7%. Non-operative treatment was indicated in 510 (63.1%) patients. Conclusion The authors presented the largest epidemiological profile regarding spine trauma in Latin America, analyzing a total of 808 patients, which represents an incidence of 134.6 cases/year. This paper fills a gap in the medical literature regarding the epidemiological profile of this disease in Latin America. Level of evidence II; Prognostic study.

[Effectiveness of limited middle and posterior column osteotomy via transvertebral space approach for old thoracolumbar compression fracture]

Objective

To investigate the effectiveness of limited middle and posterior column osteotomy via transvertebral space approach in treatment of old thoracolumbar compression fracture.

Methods

A clinical data of 47 patients with old thoracolumbar compression fractures, who met the selection criteria between January 2010 and March 2018, was retrospectively analyzed. Twenty-five patients (group A) underwent the limited middle and posterior column osteotomy via transvertebral space approach, and 22 patients (group B) underwent the pedicle subtraction osteotomy (PSO). There was no significant difference in gender, age, cause of injury, time from injury to operation, fracture segment, and preoperative Cobb angle, sagittal vertical axis (SVA), visual analogue scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and Oswestry disability index (ODI) between the two groups ( P>0.05). The operation time, intraoperative blood loss, and postoperative complications, as well as postoperative Cobb angle, SVA, VAS score, JOA score, ODI and the differences of all indexes between pre- and post-operation were recorded and compared between the two groups. The neurological function was evaluated by Frankel scale.

Results

The operations of both groups were successfully completed. The operation time and intraoperative blood loss in group A were significant lower than those in group B ( P<0.05). All incisions healed by first intetion. All patients were followed up 23-27 months (mean, 24.2 months) in group A and 24-28 months (mean, 24.8 months) in group B. At last follow-up, the VAS score, JOA score, ODI, Cobb angle, and SVA of the two groups were compared with those before operation, and the differences were significant ( P<0.05). There was no significant difference between the two groups ( P>0.05) in the indexes at last follow-up and the difference between pre- and post-operation. The lower extremity neurological symptoms (Frankel grade D) in 3 patients of group A before operation relieved (Frankel grade E) at last follow-up. The other patients were Frankel grade E. At last follow-up, CT showed bony fusion in the grafted area without any complications such as failure of internal fixation or pseudarthrosis.

Conclusion

For patients with old thoracolumbar compression fractures, the limited middle and posterior column osteotomy via transvertebral space approach has a satisfactory effectiveness. Compared with PSO, it can reduce surgical trauma on the basis of achieving the same degree of deformity correction.

Management of AO-type C thoracolumbar fractures during COVID-19 pandemic using distractor device: a novel technique

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

Management of the severe thoracolumbar (TL) spine fracture-dislocation injuries have been further complicated by the COVID-19 pandemic. The need to optimize resources and minimize the personnel in the operating room (OR) led us to develop a novel technique to reduce TL fracture-dislocations (AO type-C) using an orthopedic distractor device (ODD).

METHODS

This prospective study was conducted at a tertiary care spine center with a study duration from March 2020 to May 2020 coinciding with the nationwide lockdown and travel restrictions imposed in view of the COVID-19 crisis. Only patients with AO type C fracture-dislocation managed using the ODD operated by a single surgeon were included in the study.

RESULTS

Of 12 cases, the most commonly affected level was D12-L1. Nine patients were American Spinal Injury Association Impairment Scale (AIS) A at presentation, two patients were AIS B, and one AIS C. The mean operative time was 125 min and mean blood loss was 454 ml. Eight patients remained AIS A, one patient improved from AIS B to C. Two patients became independent walkers, one remained AIS B. The post-operative VAS score improved to a mean value of 2.33. The improvement in kyphosis was 26.24° immediate postoperatively and maintained at 25.9°, percentage height loss reduced to 2.75% immediate postoperatively and maintained at 3.16% at 3 months follow-up.

CONCLUSIONS

Management of TL fracture-dislocations in COVID times of health care resource scarcity can be challenging. Single surgeon with ODD is a useful technique for achieving good results in these injuries.

Minimally Invasive Thoracolumbar Corpectomy and Percutaneous Pedicle Screw Fixation with Computer-Assisted Rod-Bending System in Single Lateral Position: Technical Note

BACKGROUND

Thoracolumbar corpectomy and percutaneous pedicle screw (PPS) fixation is becoming the standard method for correcting and stabilizing malalignment of spine, as is often seen in osteoporotic vertebral fracture. Nowadays, this procedure can be performed in a single lateral position with navigation. For an osteoporotic spine, accurate rod bending is necessary to prevent screw back-out. We describe a new technique using the spinal rod-bending system in a single lateral position.

METHODS

A 71-year-old woman presented with severe back pain and impending paraplegia secondary to L1 osteoporotic vertebral fracture. We performed minimally invasive L1 corpectomy with an expandable vertebral cage and short-segment PPS with computer-assisted rod bending in a single lateral position under navigation guidance.

RESULTS

The patient was successfully treated with surgery, and her low back pain improved. Her clinical outcomes improved; the Oswestry Disability Index went from 54% to 26%, and her low back pain visual analog scale score went from 78 mm to 19 mm at the 2-year final follow-up.

CONCLUSIONS

Minimally invasive surgery thoracolumbar corpectomy using a computer-assisted spinal rod-bending system is a valuable technique to reduce screw back-out for osteoporotic vertebrae. With this new technique, the rod bending becomes easy, even for long PPS fusion with the severe osteoporotic or deformity patient in a single lateral position.

Timing of Surgery for Thoracolumbar Spine Trauma: Patients With Neurological Injury

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.

Variability in Management Practices and Surgical Decision Making in Spinal Tuberculosis: An Expert Survey-Based Study

Study Design

Electronic survey–based study.

Purpose

The aim of the study was to objectively review the variability in the prevailing treatment protocols and surgical decision making in the management of patients with spinal tuberculosis (TB) among spine surgeons with expertise in spinal TB across the country.

Overview of Literature

A lack of good-quality evidence, ambiguities in the national spinal TB guidelines, and the demand for early rehabilitation and a better quality of life in patients with spinal TB has led to the emergence of various gray zones in the management of spinal TB.

Methods

Seventeen fellowship-trained spinal TB experts representing different geographical regions of India completed an online survey consisting of questions pertaining to the conservative management of spinal TB (antitubercular therapy) and 30 clinical case vignettes including a wide spectrum of presentations of spinal TB with no or minimal neurological deficit. The variability in the responses for questions and case wise variability with respect to surgical decision making was assessed using the index of qualitative variation (IQV). The average tendency to operate (TTO) was calculated for various groups of respondents.

Results

High variability was observed in all questions regarding conservative spinal TB management (IQV > 0.8). Among the 30 case vignettes, 14 were found to have high variability with respect to surgical decision making (IQV > 0.8). With respect to levels of fixation, all but two cases had poor or slight agreement. Younger age and practice in a government or tertiary care teaching hospital were factors associated with a higher TTO.

Conclusions

Significant variability was detected in treatment practices for the management of spinal TB among experts. Most of the case vignettes were found to have significant heterogeneity with respect to surgical decision making, which reflects a significant lack of consensus and lacunae in literature.

Better late than never: Clinical outcomes of delayed fixation in thoracolumbar spinal trauma

PURPOSE

To analyse factors influencing functional outcome and neurological recovery in patients undergoing delayed surgery for traumatic spinal cord injury (SCI) involving thoracolumbar spine.

METHODS

Retrospective analysis of 33 patients with thoracolumbar SCI who underwent delayed surgery (≥ 72hrs post-trauma) with a minimum follow-up of 1 year (average:32.55 months) was done. The parameters studied included age, sex, co-morbidities, mode of trauma, associated trauma, level and number of vertebrae involved, fracture morphology, thoracolumbar injury classification and severity score (TLICS), maximal spinal cord compression (MSCC), signal changes in the cord, neurological deficit as per the American Spinal Injury Association (ASIA) scale, lower extremity motor score (LEMS), bowel bladder involvement, time interval between trauma and surgery.

RESULTS

Mean time interval from injury to spine surgery was 24.45 days. At the end of 1-year follow-up, 17(51.5%), 12(36.36%), and 3(9.1%) patients had ≥ 1, ≥ 2, and ≥ 3-grade ASIA improvement, respectively. The mean LEMS rose to 33.86 from 17.09 (P < 0.001). 8 out of 20 patients with bladder involvement showed improvement. 4 patients succumbed, 22 were ambulatory, and 7 remained non-ambulatory. On comparing various parameters, pre-operative LEMS score (P-value: < 0.001), cord signal changes (P-value:0.002), and presence of cord transection (P-value:0.007) differed significantly in the above-mentioned three groups, while age (P-value:0.442), average TLICS (P-value:0.872), time from injury to surgery (P-value:0.386) did not differ significantly.

CONCLUSION

This study highlights that there is still a significant scope for neurological improvement even after delayed surgery in patients with thoracolumbar SCI. The lower the LEMS score at the time of presentation, signal changes in the cord and presence of cord transection have a significant influence on unfavourable clinical outcomes at the end of 1-year post-surgery.

A modified MRI protocol for the increased detection of sacrococcygeal fractures in patients with thoracolumbar junction fractures

This study aimed to identify concurrent thoracolumbar junction (TLJ) and sacrococcygeal (SC) fractures using a modified MRI protocol and analyze the risk factors associated with tandem fractures. We retrospectively investigated patients with MRI-confirmed TLJ fractures from January 2017 to March 2020. Patients were divided into two study groups: study 1 with a modified MRI protocol and study 2 with a routine protocol. The modified protocol included an extended field of view of sagittal scans in L-spine MRI covering the full SC spine. In study 1, frequency of concurrent TLJ and SC fractures was investigated. And we analyzed risk factors and compared CT and MRI for detecting SC fractures. In study 2, co-occurrence of both fractures was investigated. A total of 176 and 399 patients with TLJ fractures were enrolled in study 1 and 2, then SC fractures were identified in 53 (30.14%) and 36 patients (9.02%), respectively. An axial loading trauma mechanism was a significant risk factor (Odds ratio 7.0, p < 0.001), and MRI was more sensitive than CT in detecting SC fractures (p < 0.002). Thus, a modified MRI protocol was useful to detect the high occurrence of SC fractures in TLJ fractures, which concurrent fractures increased by an axial loading mechanism.

[Risk factors of recurrent kyphosis in thoracolumbar burst fracture patients treated by short segmental pedicle screw fixation]

OBJECTIVE

To analyze the risk factors of recurrent kyphosis after removal of short segmental pedicle screw fixation in patients with thoracolumbar burst fractures.

METHODS

Retrospective analysis was conducted of 144 cases of thoracolumbar burst fractures without neurological impairment treated in Peking University Third Hospital from January 2010 to December 2017. There were 74 males and 70 females, with an average age of (39.1±13.2) years. The distribution of the injured vertebrae was T12: 42, L1: 72 and L2: 30, with fracture types of A3: 90, B1: 25 and B2: 29. The patients were divided into two groups: Recurrent kyphosis group (n=92) and non-recurrent kyphosis group (n=52). SPSS 26.0 software was used for univariate analysis and Logistic regression analysis.

RESULTS

The average follow-up time was 28 (20-113) months. The imaging indexes of pre-operation, 3 days post-operation, 12 months post-operation and the last follow-up were measured and compared. Anterior vertebral body height, segmental kyphosis, vertebral wadge angle and Gardner deformity were significantly improved after operation (P < 0.05), and there were some degrees of loss in the 1-year follow-up; anterior vertebral body height and vertebral wadge angle were no longer changed after the removal of the screws; however, segmental kyphosis and Gardner deformity were still aggravated after the removal of the screws (P < 0.05). There were some degrees of collapse of the height of the upper and lower discs during the follow-up. Univariate analysis showed that there were statistically significant differences (P < 0.05) between the two groups in gender, age (36.9 years vs. 43.0 years), upper disc injury, CT value (174 vs. 160), segmental kyphosis (16.6° vs. 13.3°), vertebral wadge angle (16.7° vs. 13.6°), Gardner deformity (19.1° vs. 15.2°) and ratio of anterior vertebral body height (0.65 vs. 0.71). Logistic regression analysis showed that male (OR: 2.88, 95%CI: 1.196-6.933), upper disc injury (OR: 2.962, 95%CI: 1.062-8.258) and injured vertebral wedge angle were risk factors of recurrent kyphosis after removal of internal fixation for thoracolumbar burst fracture (P < 0.05).

CONCLUSION

The patients with thoracolumbar burst fracture can obtain satisfactory effect immediately after posterior short segmental pedicle screw fixation, however, there may be some degree of loss during the follow-up. Male, upper disc injury and injured vertebral wedge angle are the risk factors of recurrent kyphosis after removal of internal fixation for thoracolumbar burst fracture.

Prediction of Incidental Osteoporotic Fractures at Vertebral-Specific Level Using 3D Non-Linear Finite Element Parameters Derived from Routine Abdominal MDCT

To investigate whether finite element (FE) analysis of the spine in routine thoracic/abdominal multi-detector computed tomography (MDCT) can predict incidental osteoporotic fractures at vertebral-specific level; Baseline routine thoracic/abdominal MDCT scans of 16 subjects (8(m), mean age: 66.1 ± 8.2 years and 8(f), mean age: 64.3 ± 9.5 years) who sustained incidental osteoporotic vertebral fractures as confirmed in follow-up MDCTs were included in the current study. Thoracic and lumbar vertebrae (T5-L5) were automatically segmented, and bone mineral density (BMD), finite element (FE)-based failure-load, and failure-displacement were determined. These values of individual vertebrae were normalized globally (g), by dividing the absolute value with the average of L1-3 and locally by dividing the absolute value with the average of T5-12 and L1-5 for thoracic and lumbar vertebrae, respectively. Mean-BMD of L1-3 was determined as reference. Receiver operating characteristics (ROC) and area under the curve (AUC) were calculated for different normalized FE (Kload, Kdisplacement,K(load)g, and K(displacement)g) and BMD (KBMD, and K(BMD)g) ratio parameter combinations for identifying incidental fractures. Kload, K(load)g, KBMD, and K(BMD)g showed significantly higher discriminative power compared to standard mean BMD of L1-3 (BMDStandard) (AUC = 0.67 for Kload; 0.64 for K(load)g; 0.64 for KBMD; 0.61 for K(BMD)g vs. 0.54 for BMDStandard). The combination of Kload, Kdisplacement, and KBMD increased the AUC further up to 0.77 (p < 0.001). The combination of FE with BMD measurements derived from routine thoracic/abdominal MDCT allowed an improved prediction of incidental fractures at vertebral-specific level.

Epidemiology and clinical outcomes of spinal cord injuries at a level II trauma centre in Nigeria: a longitudinal five year study

BACKGROUND

Spinal cord injuries (SCIs) are devastating consequences of traumatic injuries with far-reaching health and socioeconomic implications. The objectives of this study were to describe the epidemiological characteristics of traumatic SCI and to analyse these epidemiological and clinical characteristics.

METHODS

This study was a retrospective observational study. We extracted data from the medical records of all cases of acute traumatic SCI that presented at the hospital between January 2013 and December 2017.

RESULTS

We recorded 99 cases of traumatic SCI over the study period. The patients' mean age was 37.15 ± 13.5 years with a male predominance (68.7%). Working age group accounted for 83.9% of cases. Motor vehicular accident (MVA) and falls accounted for 62.6% and 22.2% respectively. About a third of the cases (32.3%) presented within 24 hours of injury. The most frequently affected level was the cervical spine (63.6%), and complete tetraplegia was the most prevalent clinical pattern (31.3%). American Spinal Injury Association impairment scale (AIS) improved in 31.3% of cases. Twenty-nine patients (30.2%) had morbidity, with 21.2% developing pressure sores. Mortality accounted for 3%.

CONCLUSIONS

Motor vehicular crash and fall-related traumatic SCI affected mostly males and the working age group with complete tetraplegia as the predominating clinical pattern. There is a need for strategic interventions to reduce MVA and improve pre-hospital care and health policies to ensure early definitive care.