Predicting early complications in patients with spinal gunshot wounds: A multicenter study

Introduction

There is a wide variation in the clinical presentation of spinal gunshot wounds ranging from isolated minor stable fractures to extremely severe injuries with catastrophic neurological damage.

Research question

we aim to analyze the risk factors for early complications and impact of surgical treatment in patients with spinal gunshot wounds.

Material and methods

This is a multicentre retrospective case-control study to compare patients with spinal gunshot wounds who had early complications with those who did not. The following matching criteria were used: sex (1:1), injury level (1:1) and age (±5 years). Univariate and multivariate analyses were performed using logistic regression.

Results

Results: Among 387 patients, 36.9 % registered early complications, being persistent pain (n = 32; 15 %), sepsis/septic shock (n = 28; 13 %), pneumonia (n = 27; 13 %) and neurogenic bladder (n = 27; 12 %) the most frequently reported. After case-control matched analysis, we obtained 133 patients who suffered early complications (cases) and 133 patients who did not as control group, not differing significantly in sex (p = 1000), age (p = 0,535) and injury level (p = 1000), while the 35 % of complications group required surgical treatment versus 15 % of the non-complication group (p < 0.001). On multivariable analysis, significant predictors of complications were surgical treatment for spinal injury (OR = 3.50, 95 % CI = 1.68-7.30), dirty wound (3.32, 1.50-7.34), GCS ≤8 (3.56, 1.17-10.79), hemodynamic instability (2.29, 1.07-4.88), and multiple bullets (1.97, 1.05-3.67).

Discussion and conclusion

Spinal gunshot wounds are associated with a high risk of early complications, especially when spinal surgery is required, and among patients with dirty wound, low level of consciousness, hemodynamic instability, and multiple bullets.

Minimally Invasive Surgery for Traumatic Thoracolumbar Fractures: A Cross-Sectional Study of Spine Surgeons

OBJECTIVE

To describe the perceived feasibility of minimally invasive surgical treatment of thoracolumbar fractures among spine surgeons in Latin American centers.

METHODS

This is a cross-sectional study on minimally invasive surgical treatment for unstable thoracolumbar fractures. We conducted an online survey of spine surgeons working in Latin American centers, administered between December 16, 2022 and January 15, 2023. A nonprobabilistic sample was selected (snowball sampling). A questionnaire was sent by email and other messaging applications.

RESULTS

Data were extracted from 134 surgeons. The majority of the respondents were from Brazil (n = 30, 22.4%), Mexico (n = 24, 17.9%), Argentina (n = 22, 16.4%), and Chile (n = 15, 11.2%). Their mean age was 46.53 years (standard deviation, 9.7; range 31-67) and almost all were males (n = 128, 95.5%). Most respondents were orthopedists (n = 85, 63.4%) or neurosurgeons (n = 49, 36.9%). Most of the respondents (n = 110, 82.1%) reported at least some difficulty using minimally invasive techniques for thoracolumbar fractures. It should be noted that there were significant regional differences between the surgeons' responses (P = 0.017). Chilean surgeons reported better results than others.

CONCLUSION

Spinal surgeons from Latin American centers have identified challenges and obstacles to performing minimally invasive surgery for thoracolumbar trauma. The survey found that a majority of respondents experienced some level of difficulty, with regional variations. The most frequently reported difficulties were the high cost of the procedure, patient insurance restrictions, and long insurance approval times.

CT Scan in Subaxial Cervical Facet Injury: Is It Enough for Decision-Making?

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

Assessment of subaxial cervical facet injuries using the AO Spine Subaxial Cervical Spine Injury Classification System is based on CT scan findings. However, additional radiological evaluations are not directly considered. The aim of this study is to determine situations in which spine surgeons request additional radiological exams after a facet fracture.

METHODS

A survey was sent to AO Spine members from Latin America. The evaluation considered demographic variables, routine use of the Classification, as well as the timepoint at which surgeons requested a cervical MRI, a vascular study, and/ or dynamic radiographs before treatment of facet fractures.

RESULTS

There was 229 participants, mean age 42.9 ± 10.2 years; 93.4% were men. Orthopedic surgeons 57.6% with 10.7 ± 8.7 years of experience in spine surgery. A total of 86% used the Classification in daily practice. An additional study (MRI/vascular study/and dynamic radiographs) was requested in 53.3%/9.6%/43.7% in F1 facet injuries; 76.0%/20.1%/50.2% in F2; 89.1%/65.1%/28.4% in F3; and 94.8%/66.4%/16.6% in F4. An additional study was frequently required: F1 72.5%, F2 86.9%, F3 94.7%, and F4 96.1%.

CONCLUSIONS

Spine surgeons generally requested additional radiological evaluations in facet injuries, and MRI was the most common. Dynamic radiographs had a higher prevalence for F1/F2 fractures; vascular studies were more common for F3/F4 especially among surgeons with fewer years of experience. Private hospitals had a lower spine trauma cases/year and requested more MRI and more dynamic radiographs in F1/F2. Neurosurgeons had more vascular studies and dynamic radiographs than orthopedic surgeons in all facet fractures.

Is Indirect Decompression and Fusion More Effective than Direct Decompression and Fusion for Treating Degenerative Lumbar Spinal Stenosis With Instability? A Systematic Review and meta-Analysis

Study design: Systematic Review and Meta-analysis.Objective: Surgical alternatives to treat lumbar spinal stenosis and instability include indirect (ALIF, OLIF, and LLIF) and direct (TLIF or posterior lumbar interbody fusion) decompression and fusion interventions. Although both approaches have proven to be effective in reducing symptoms, it is unknown if there is any difference in effectiveness between them. In this systematic review and meta-analysis, we aimed to evaluate postoperative pain and disability in patients treated whit indirect vs direct decompression and fusion approaches.Methods: We conducted a systematic review of the literature consulting several databases and identified studies that enrolled patients diagnosed with degenerative lumbar spinal stenosis and instability treated with indirect or direct decompression and fusion techniques. Our primary endpoints were the visual analogue scale, Oswestry Disability Index, and the Japanese Orthopedics Association Back Pain Evaluation Questionnaire 1 year after the procedure. Secondary outcomes included complication rate, blood loss, and surgical time.Results: Nine retrospective and comparative studies were included enrolling a total of 1004 participants. Both surgical strategies had satisfactory clinical outcomes with no significant difference at 1 year. Although the complication rate was similar for both groups, the profile of the adverse events was different. In addition, patients treated with indirect decompression and fusion had significantly less blood loss and operative times.Conclusions: Indirect and direct decompression and fusion techniques are similarly effective in treating patients with lumbar spinal stenosis and instability. The ID group had significantly lower intraoperative blood loss and surgical time values.

Risk Factors for Postoperative Complications After Surgical Treatment of Type B and C Injuries of the Thoracolumbar Spine

BACKGROUND

Unstable thoracolumbar spinal injuries benefit from surgical fixation. However, perioperative complications significantly affect outcomes in surgicallytreated spine patients. We evaluated associations between risk factors and postoperative complications in patients surgically treated for thoracolumbar spine fractures.

METHODS

We conducted a retrospective multicenter study collating data from 21 spine centers across 9 countries on the treatment of AOSpine types B and C injuries of the thoracolumbar spine treated via a posterior approach. Comparative analysis was performed between patients with postoperative complications and those without. Univariate and multivariable analyses were performed.

RESULTS

Among 535 patients, at least 1 complication occurred in 43%. The most common surgical complication was surgical-site infection (6.9%), while the most common medical complication was urinary tract infection (13.8%). Among 136 patients with American Spinal Injury Association (ASIA) Impairment Scalelevel A disability, 77.9% experienced at least 1 complication. The rate of complications also rose sharply among patients waiting >3 days for surgery (P<0.001), peaking at 68.4% among patients waiting ≥30 days. On multivariable analysis, significant predictors of complications were surgery at a governmental hospital (odds ratio = 3.38, 95% confidence interval = 1.73-6.60), having ≥1 comorbid illness (2.44, 1.61-3.70), surgery delayed due to health instability (2.56, 1.50-4.37), and ASIA Impairment Scalelevel A (3.36, 1.78-6.35), while absence of impairment (0.39, 0.22-0.71), ASIAlevel E (0.39, 0.22-0.67) and, unexpectedly, delay caused by operating room unavailability (0.60, 0.36-0.99) were protective.

CONCLUSIONS

Types B and C thoracolumbar spine injuries are associated with a high risk of postoperative complications, especially common at governmental hospitals, and among patients with comorbidity, health instability, longer delays to surgery, and worse preoperative neurologic status.

Unstable Thoracolumbar Injuries: Factors Affecting the Decision for Short-Segment vs Long-Segment Posterior Fixation

BACKGROUND

Factors influencing the length of spinal instrumentation have been mostly evaluated in burst fractures, receiving more attention than other unstable thoracolumbar injuries. We aimed to evaluate clinical factors affecting surgical decision-making and associated complications.

METHODS

This was a multicentric retrospective cohort study. Outcomes of patients with AO Spine injury classification types B2, B3, and C operated through an open posterior-only approach were analyzed. Length of instrumentation was correlated with age, type of injury, comorbidities, level of injury, neurological status, and complications.

RESULTS

Among 439 patients, 30.3% underwent short-segment fixation (SSF) and 69.7% underwent long-segment fixation (LSF). Type C injuries were treated with LSF in 89.4% of cases (P < 0.001). On multivariate analysis, age ≤39 years (OR: 2.06), AO spine type B2 (OR: 3.58), and type B3 (OR: 7.48) were statistically significant predictors for SSF, while hypertension (OR: 4.07), upper thoracic injury (OR: 9.48), midthoracic injury (OR: 6.06), and American Spinal Injury Association Impairment Scale A (OR: 3.14) were significantly associated with LSF. Patients with SSF had fewer overall complications (27.1% vs 50.9%, P < 0.001) and were less likely to develop pneumonia (6.0% vs 18.3%, P < 0.001) and urinary tract infections (6.8% vs 16.3%, P < 0.007).

CONCLUSIONS

Unstable thoracolumbar injuries were mostly treated by LSF. Length of instrumentation was affected by the type of spinal injury, location of the injury, and neurological status. SSF was associated with lower rates of early complications than LSF.

CLINICAL RELEVANCE

The decision on the length of fixation in the surgical treatment of unstable thoracolumbar injuries is affected by different factors, and it will impact the rate of postoperative complications.

LEVEL OF EVIDENCE: 3

Reliability Evaluation of the New AO Spine-DGOU Classification for Osteoporotic Thoracolumbar Fractures

OBJECTIVES

To perform an interobserver and intraobserver agreement evaluation of the new AO Spine-DGOU classification system for osteoporotic thoracolumbar fractures (OFc).

METHODS

Complete imaging studies of 97 patients (radiographs, computed tomography scans, and magnetic resonance imaging) with osteoporotic thoracolumbar fractures were selected and classified using the OFc by 6 spine surgeons (3 senior surgeons with more than 15 years of experience and 3 surgeons with less than 15 years). After a 4-week interval, the same cases were presented to the same evaluators in a random sequence for a new classification assessment. The weighted kappa coefficient (wκ) was used to determine the interobserver and intraobserver agreement.

RESULTS

The interobserver agreement was moderate, wκ = 0.59 (95% confidence interval 0.54-0.64). The intraobserver agreement was fair, wκ = 0.35 (95% confidence interval 0.29-0.40). Interobserver agreement slightly improved for junior staff between first and second evaluation, suggesting a learning effect. Better agreement was obtained by senior staff at the interobserver and intraobserver agreement.

CONCLUSIONS

This independent assessment demonstrated that new OFc allows moderate interobserver agreement and fair intraobserver agreement. Further studies are necessary prior to its widespread adoption.

Genotoxic parameters of human degenerated intervertebral discs are linked to the pathogenesis of disc degeneration

BACKGROUND

Degenerative disc disease (DDD) is a prevalent disorder that brings great incapacity and morbidity to the world's population. Its pathophysiology is not fully understood. DNA damage can influence this process, but so far, there have been few studies to evaluate this topic and its true importance in DDD, as well as whether there is a relation between degeneration grade and DNA damage. The objective of this study is to evaluate the degree of damage to the DNA and the relation to the severity of DDD and measure its response to this insult compared to live/dead cell parameters and reactive oxygen species activity in human discs.

METHODS

An experimental study was performed with 15 patients with grade IV or V Pfirrmann classification who underwent spinal surgery. Five patients were operated on two levels, resulting in 20 samples that were submitted to the comet assay to measure DNA damage. Of these, six samples were submitted to flow cytometry, and apoptosis, necrosis, cell membrane integrity, intracellular esterase activity, reactive oxygen species (ROS), caspase 3 and mitochondrial membrane potential were evaluated.

RESULTS

All samples had DNA damage, and the average of index damage (ID) was 78.1 (SD ± 65.11) and frequency damage (FD) was 49.3% (SD ± 26,05%). There was no statistical difference between the Pfirrmann grades and genotoxic damage. Likewise, all samples that underwent flow cytometry showed apoptosis and ROS to many different degrees.

CONCLUSIONS

DNA damage occurs in high-grade degeneration of human discs and contributes to activation of the apoptosis pathway and ROS production that can accelerate disc degeneration.

Vertebral augmentation plus short-segment fixation versus vertebral augmentation alone in Kümmell's disease: a systematic review and meta-analysis

Osteoporotic vertebral compression fractures of the thoracolumbar spine can progress to Kümmell's disease, an avascular vertebral osteonecrosis. Vertebral augmentation (VA)-vertebroplasty and/or kyphoplasty-is the main treatment modality, but additional short-segment fixation (SSF) has been recommended concomitant to VA. The aim is to compare clinical and radiological outcomes of VA + SSF versus VA alone. Systematic review, including comparative articles in Kümmell's disease, was performed. This study assessed the following outcome measurements: visual analog scale (VAS), Oswestry Disability Index (ODI), anterior vertebral height (AVH), local kyphotic angle (LKA), operative time, blood loss, length of stay, and cement leakage. Six retrospective studies were included, with 126 patients in the VA + SSF group and 152 in VA alone. Pooled analysis showed the following: VAS, non-significant difference favoring VA + SSF: MD -0.61, 95% CI (-1.44, 0.23), I² 91%, p = 0.15; ODI, non-significant difference favoring VA + SSF: MD -9.85, 95% CI (-19.63, -0.07), I² 96%, p = 0.05; AVH, VA + SSF had a non-significant difference over VA alone: MD -3.21 mm, 95% CI (-7.55, 1.14), I² 92%, p = 0.15; LKA, non-significant difference favoring VA + SSF: MD -0.85°, 95% CI (-5.10, 3.40), I² 95%, p = 0.70. There were higher operative time, blood loss, and hospital length of stay for VA + SSF (p < 0.05), but with lower cement leakage (p < 0.05). VA + SFF and VA alone are effective treatment modalities in Kümmell's disease. VA + SSF may provide superior long-term results in clinical and radiological outcomes but required a longer length of stay.

Time to Surgery for Unstable Thoracolumbar Fractures in Latin America-A Multicentric Study

OBJECTIVE

We sought to identify delays for surgery to stabilize unstable thoracolumbar fractures and the main reasons for them across Latin America.

METHODS

We reviewed the charts of 547 patients with type B or C thoracolumbar fractures from 21 spine centers across 9 Latin American countries. Data were collected on demographics, mechanism of trauma, time between hospital arrival and surgery, type of hospital (public vs. private), fracture classification, spinal level of injury, neurologic status (American Spinal Injury Association impairment scale), number of levels instrumented, and reason for delay between hospital arrival and surgical treatment.

RESULTS

The sample included 403 men (73.6%) and 144 women (26.3%), with a mean age of 40.6 years. The main mechanism of trauma was falls (44.4%), followed by car accidents (24.5%). The most frequent pattern of injury was B2 injuries (46.6%), and the most affected level was T12-L1 (42.2%). Neurologic status at admission was 60.5% intact and 22.9% American Spinal Injury Association impairment scale A. The time from admission to surgery was >72 hours in over half the patients and over a week in >25% of them. The most commonly reported reasons for surgical delay were clinical instability (22.9%), lack of operating room availability (22.7%), and lack of hardware for spinal instrumentation (e.g., screws/rods) (18.8%).

CONCLUSIONS

Timing for surgery in this sample of unstable fractures was over 72 hours in more than half of the sample and longer than a week in about a quarter. The main reasons for this delay were clinical instability and lack of economic resources. There is an apparent need for increased funding for the treatment of spinal trauma patients in Latin America.

Metastatic prolactinoma: case report with immunohistochemical assessment for p53 and Ki-67 antigens

Pituitary carcinomas are rare neoplasms characterized by craniospinal and/or systemic metastases originated from the pituitary. Their histopathology is frequently indistinguishable from that of benign adenomas. The development of markers that better reflect their behavior is desirable. We present the case of a 47 year-old man with a prolactin-secreting macroadenoma who was submitted to surgeries, cranial radiation therapy, and bromocriptine treatment, but evolved to a fatal outcome after the disclosure of intracranial metastases. Tumor samples underwent p53 and Ki-67 immunohistochemical assessment. p53 was absent in all samples, a rare finding among pituitary carcinomas. Ki-67 proliferative index was 2.80% in the original tumor, 4.40% in the relapse, and 4.45% in the metastasis. The figure in the relapse is higher than the expected for a noninvasive adenoma. In conclusion, p53 staining is not positive in all pituitary carcinomas. A high Ki-67 proliferative index in a pituitary adenoma might indicate a more aggressive behavior.