Paediatric spine injuries in the thoracic and lumbar spine-results of the German multicentre CHILDSPINE study

BACKGROUND

Paediatric thoracolumbar spine injuries are rare, and meaningful epidemiological data are lacking.

OBJECTIVES

The aim of this study was to provide epidemiological data for paediatric patients with thoracolumbar spinal trauma in Germany with a view to enhancing future decision-making in relation to the diagnostics and treatment of these patients.

MATERIALS AND METHODS

A retrospective multicentre study includes patients up to 16 years of age who were suffering from thoracolumbar spine injuries who had been treated in six German spine centres between 01/2010 and 12/2016. The clinical database was analysed for patient-specific data, trauma mechanisms, level of injury, and any accompanying injuries. Diagnostic imaging and subsequent treatment were investigated. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years) and age group III (10-16 years).

RESULTS

A total of 153 children with 345 thoracolumbar spine injuries met the inclusion criteria. The mean age at the time of hospitalization due to the injury was 12.9 (± 3.1) years. Boys were likelier to be affected (1:1.3). In all age groups, falls and traffic accidents were the most common causes of thoracolumbar spine injuries. A total of 95 patients (62.1%) were treated conservatively, while 58 (37.9%) of the children underwent surgical treatment. Minimally invasive procedures were the most chosen procedures. Older children and adolescents were likelier to suffer from higher-grade injuries according to the AOSpine classification. The thoracolumbar junction (T11 to L2) was the most affected level along the thoracolumbar spine (n = 90). Neurological deficits were rarely seen in all age groups. Besides extremity injuries (n = 52, 30.2%), head injuries represented the most common accompanying injuries (n = 53, 30.8%). Regarding spinal injuries, most of the patients showed no evidence of complications during their hospital stay (96.7%).

CONCLUSIONS

The thoracolumbar junction was more frequently affected in older children and adolescents. The majority of thoracolumbar spinal column injuries were treated conservatively. Nevertheless, 37.9% of hospitalized children had to be treated surgically, and there was an acceptable complication rate for the surgeries that were performed.

Biomechanical comparative study of midline cortical vs. traditional pedicle screw trajectory in osteoporotic bone

INTRODUCTION

In lumbar spinal stabilization pedicle screws are used as standard. However, especially in osteoporosis, screw anchorage is a problem. Cortical bone trajectory (CBT) is an alternative technique designed to increase stability without the use of cement. In this regard, comparative studies showed biomechanical superiority of the MC (midline cortical bone trajectory) technique with longer cortical progression over the CBT technique. The aim of this biomechanical study was to comparatively investigate the MC technique against the not cemented pedicle screws (TT) in terms of their pullout forces and anchorage properties during sagittal cyclic loading according to the ASTM F1717 test.

METHODS

Five cadavers (L1 to L5), whose mean age was 83.3 ± 9.9 years and mean T Score of -3.92 ± 0.38, were dissected and the vertebral bodies embedded in polyurethane casting resin. Then, one screw was randomly inserted into each vertebra using a template according to the MC technique and a second one was inserted by freehand technique with traditional trajectory (TT). The screws were quasi-static extracted from vertebrae L1 and L3, while for L2, L4 and L5 they were first tested dynamically according to ASTM standard F1717 (10,000 cycles at 1 Hz between 10 and 110 N) and then quasi-static extracted. In order to determine possible screw loosening, there movements were recorded during the dynamic tests using an optical measurement system.

RESULTS

The pull-out tests show a higher pull-out strength for the MC technique of 555.4 ± 237.0 N compared to the TT technique 448.8 ± 303.2 N. During the dynamic tests (L2, L4, L5), 8 out of the 15 TT screws became loose before completing 10,000 cycles. In contrast, all 15 MC screws did not exceed the termination criterion and were thus able to complete the full test procedure. For the runners, the optical measurement showed greater relative movement of the TT variant compared to the MC variant. The pull-out tests also revealed that the MC variant had a higher pull-out strength, measuring at766.7 ± 385.4 N, while the TT variant measured 637.4 ± 435.6 N.

CONCLUSION

The highest pullout forces were achieved by the MC technique. The main difference between the techniques was observed in the dynamic measurements, where the MC technique exhibited superior primary stability compared to the conventional technique in terms of primary stability. Overall, the MC technique in combination with template-guided insertion represents the best alternative for anchoring screws in osteoporotic bone without cement.

Does the use of epicutaneous vacuum-assisted closure after revision surgery on the spine reduce further wound revision surgery?

PURPOSE

This study aimed to investigate the effect of epicutaneous vacuum therapy on the rate of unplanned spinal wound revisions compared with conventional wound dressing.

METHODS

This retrospective study included patients who underwent unplanned revision spine surgery after primary aseptic spine surgery who were treated at a level I spine centre between December 2011 and December 2019. Patients with revision surgery who required a further unplanned revision surgery during the inpatient stay were considered a treatment failure. The epicutaneous vacuum-assisted closure (Epi-VAC) therapy was the standard treatment method beginning in 2017 (the epi-VAC group). Before, conventional wound dressing was used (the control group (CG)). In addition, a one-to-one matched-pair comparison analysis was performed between both groups.

RESULTS

Of 218 patients, 48 were in the epi-VAC group. The mean age was 65.1 years (epi-VAC 68.2 to CG 64.3 years (P = 0.085)), and the mean body mass index (BMI) was 28.2 kg/m² (epi-VAC 29.4 to CG 27.9 kg/m² (P = 0.16)). No significant differences in the treatment failure rate could be detected between the two groups (epi-VAC 25% to CG 22.4% (P = 0.7)). There was also no significant difference for the matched-pair analysis (epi-VAC 26.1% to CG 15.2% (P = 0.3)). An elevated CRP level (C-reactive protein) immediately before the first wound revision was a significant risk factor for further revision surgery (treatment failure: 135.2 ± 128.6; no treatment failure: 79.7 ± 86.1 mg/l (P < 0.05)).

CONCLUSION

Concerning repeat unplanned wound revision after spinal revision surgery, we cannot demonstrate an advantage of the epicutaneous vacuum therapy over conventional wound dressing.

Impact of Multifidus Muscle Atrophy on the Occurrence of Secondary Symptomatic Adjacent Osteoporotic Vertebral Compression Fractures

To assess the potential influence of multifidus atrophy and fatty degeneration on the incidence of adjacent vertebral compression fractures within one year after the index fracture. In a retrospective cohort study, patients who underwent surgery for an OVCF were identified and baseline characteristics, fracture patterns and the occurrence of secondary adjacent fractures within one year were obtained by chart review. Multifidus muscle atrophy and fatty degeneration were determined on preoperative MRI or CT scans. In this analysis of 191 patients (mean age 77 years, SD 8, 116 female), OF type 3 was the most common type of OVCF (49.2%). Symptomatic adjacent OVCFs within one year after index fracture were observed in 23/191 patients (12%) at mean 12, SD 12 weeks (range 1-42 weeks) postoperatively. The mean multifidus muscle area was 264, SD 53 mm² in patients with an adjacent vertebral fracture and 271, SD 92 mm² in patients without a secondary fracture (p = 0.755). Mean multifidus fatty infiltration was graded Goutallier 2.2, SD 0.6 in patients with an adjacent fracture and Goutallier 2.2, SD 0.7 in patients without an adjacent fracture (p = 0.694). Pre-existing medication with corticosteroids was associated with the occurrence of an adjacent fracture (p = 0.006). Multifidus area and multifidus fatty infiltration had no significant effect on the occurrence of adjacent vertebral fractures within one year after the index fracture. Patients with a pre-existing medication with corticosteroids were more likely to sustain an adjacent fracture.

Risk factors for wound-related complications after surgical stabilization of spinal metastases with a special focus on the effect of postoperative radiation therapy

BACKGROUND

Advancements in the field of oncological therapies during the last decades have led to a significantly prolonged survival of cancer patients. This has led to an increase in the incidence of spinal metastases. The purpose of this study was to assess risk factors for wound-related complications after surgical stabilization of spinal metastases with a special focus on the effect of postoperative RT and its timing.

METHODS

Patients who had been treated for metastatic spine disease by surgical stabilization followed by radiotherapy between 01/2012 and 03/2019 were included and a retrospective chart review was performed.

RESULTS

Of 604 patients who underwent stabilizing surgery for spinal metastases, 237 patients (mean age 66 years, SD 11) with a mean follow-up of 11 months (SD 7) were eligible for further analysis. Forty-one patients (17.3%) had wound-related complications, 32 of them before and 9 after beginning of the RT. Revision surgery was necessary in 26 patients (11.0%). Body weight (p = 0.021), obesity (p = 0.018), ASA > 2 (p = 0.001), and start of radiation therapy within 21 days after surgery (p = 0.047) were associated with an increased risk for wound complications. Patients with chemotherapy within 3 weeks of surgery (12%) were more likely to have a wound-related surgical revision (p = 0.031).

CONCLUSION

Body weight, obesity and ASA > 2 were associated with an increased risk for wound complications. Patients with chemotherapy within 3 weeks of the surgery were more likely to have a wound-related revision surgery. Patients who had begun radiation therapy within 21 days after surgery were more likely to have a wound complication compared to patients who waited longer.

A Biomechanical Model for Testing Cage Subsidence in Spine Specimens with Osteopenia or Osteoporosis Under Permanent Maximum Load

BACKGROUND

Intervertebral fusions in cases of reduced bone density are a tough challenge. From a biomechanical point of view, most current studies have focused on the range of motion or have shown test setups for single-component tests. Definitive setups for biomechanical testing of the primary stability of a 360° fusion using a screw-rod system and cage on osteoporotic spine are missing. The aim of this study was to develop a test stand to provide information about the bone-implant interface under reproducible conditions.

METHODS

After pretesting with artificial bone, functional spine units were tested with 360° fusion in the transforaminal lumbar interbody fusion technique. The movement sequences were conducted in flexion/extension, right and left lateral bending, and right and left axial rotation on a human model with osteopenia or osteoporosis under permanent maximum load with 7.5 N-m.

RESULTS

During the testing of human cadavers, 4 vertebrae were fully tested and were inconspicuous even after radiological and macroscopic examination. One vertebra showed a subsidence of 2 mm, and 1 vertebra had a cage collapsed into the vertebra.

CONCLUSIONS

This setup is suitable for biomechanical testing of cyclical continuous loads on the spine with reduced bone quality or osteoporosis. The embedding method is stable and ensures a purely single-level setup with different trajectories, especially when using the cortical bone trajectory. Optical monitoring provides a very accurate indication of cage movement, which correlates with the macroscopic and radiological results.

[Posttraumatic vertebral disc alterations after B and C type spinal injuries in childhood-Clinical and radiological 10-year results for two cases]

Pediatric traumatic vertebral injuries usually present as stable A (AOspine classification) fractures, whereas B and C injuries are relatively uncommon. In contrast to adults the appropriate treatment strategy in children remains an issue of debate.The data from two pediatric patients admitted with B and C type spinal injuries in 2007 and 2008 were retrospectively analyzed. The initial diagnostics were performed via computed tomography (CT) and an additional magnetic resonance imaging (MRI) was carried out in one case.The clinical and radiological follow-up controls were carried out after 77 and 66 months as well as 123 and 112 months, respectively. In both cases thoracolumbar MRI scans revealed degenerative alterations of the ventral half of the L1/L2 disc with a regular disc signal in the dorsal segment at the first follow-up and a progressive disc degeneration in one patient at the second follow-up.Surgical treatment of pediatric B and C type injuries via open reduction and temporary monosegmental posterior screw and rod instrumentation results in satisfactory clinical and radiological outcomes. In the absence of vertebral burst fractures, the function and stability of discoligamentous injuries in children can be restored without any additional osseous fusion.

[Diagnostics and treatment of cervical spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]

BACKGROUND

Severe cervical spine injuries in children under the age of 17 years are rare. Recommendations or even guidelines for the diagnostics and treatment of such injuries in children are currently not available.

OBJECTIVE

The aim of the study was to formulate recommendations for diagnostics and treatment of injuries of the cervical spine in pediatric patients.

MATERIAL AND METHODS

First, a search of primary and secondary literature on the topic complex of diagnostics and treatment of cervical spine injuries in children was carried out. An appropriate internal literature database was defined and maintained. Second, within the framework of 9 meetings from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) systematically formulated recommendations for the diagnostics and treatment of injuries of the cervical spine in pediatric patients by a consensus process.

RESULTS

Recommendation for the diagnostics and treatment for injuries of the cervical spine could be formulated for three age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). The diagnostic and therapeutic principles known from adult patients suffering from injuries to the cervical spine cannot be easily transferred to pediatric patients.

CONCLUSION

Injuries to the pediatric spine are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. Classification systems and therapeutic recommendations for injuries to the cervical spine known from adult patients could also be used for adolescent patients. This is not possible for children under the age of 10 years. Only few classification systems exist for this age group. Basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical relationships as well as the protection of all neural structures.

[Pediatric spine trauma-Results of a German national multicenter study including 367 patients]

BACKGROUND

In general, pediatric spinal injuries are rare. No reliable data on the epidemiology of spinal injuries in pediatric patients in Germany are available. Especially in pediatric patients, for whom the medical history, clinical examination and the performance of imaging diagnostics are difficult to obtain, all available information on a spinal injury must be taken into account.

OBJECTIVE

The aim of this study was to provide epidemiological data for pediatric patients with spinal trauma in Germany in order to enhance future decision-making for the diagnostics and treatment of these patients.

MATERIAL AND METHODS

Within the framework of a national multicenter study, data were retrospectively obtained from 6 German spine centers for 7 years between January 2010 and December 2016. In addition to the demographic data, the clinical databases were screened for specific trauma mechanisms, level of injury as well as accompanying injuries. Furthermore, diagnostic imaging and the treatment selected were also analyzed.

RESULTS

A total of 367 children (female: male = 1:1.2) with a total of 610 spinal injuries were included in this study. The mean age was 12 years (±3.5 years). The most frequent trauma mechanisms were falls from <3 m and traffic accidents. The imaging diagnostics were only rarely carried out with the child under anesthesia. Younger children (0-9 years old) suffered more injuries to the cervical spine, whereas injuries to the thoracic and lumbar spine were more frequently found in older children (>10 years old). The children frequently showed accompanying injuries to the head and the extremities. Accompanying spinal injuries mostly occurred in adjacent regions and only rarely in other regions. Around 75% of the children were treated conservatively.

CONCLUSION

The results were different from the knowledge obtained from adult patients with spinal trauma and describe the special circumstances for pediatric patients with spinal trauma. Despite certain limitations these facts may help to enhance future decision-making for the diagnostics and treatment of these patients.

[Diagnostics and treatment of thoracic and lumbar spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]

BACKGROUND

Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist.

OBJECTIVE

The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients.

MATERIAL AND METHODS

Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process.

RESULTS

Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients.

CONCLUSION

Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.

Epidemiology and management of atlas fractures

PURPOSE

The purpose of this study was to gain new insights into the epidemiologic characteristics of patients with atlas fractures and to retrospectively evaluate complication rates after surgical and non-surgical treatment.

METHODS

In a retrospective study, consecutive patients diagnosed with a fracture of the atlas between 01/2008 and 07/2018 were analyzed. Data on epidemiology, concomitant injuries, fracture patterns and complications were obtained by chart and imaging review.

RESULTS

In total, 189 patients (mean age 72 years, SD 19; 57.1% male) were treated. The most frequent trauma mechanism was a low-energy trauma (59.8%). A concomitant injury of the cervical spine was found in 59.8%, a combined C1/C2 injury in 56.6% and a concomitant fracture of the thoraco-lumbar spine in 15.4%. When classified according to Gehweiler, there were: 23.3% type 1, 22.2% type 2, 32.8% type 3, 19.0% type 4 and 1.1% type 5. Treatment of isolated atlas fractures (n = 67) consisted of non-operative management in 67.1%, halo fixation in 6.0% and open surgical treatment in 26.9%. In patients with combined injuries, the therapy was essentially dictated by the concomitant subaxial cervical injuries.

CONCLUSIONS

Atlas fractures occurred mainly in elderly people and in the majority of the cases were associated with other injuries of the head and spine. Most atlas fractures were treated conservatively. However, surgical treatment has become a safe and valid option in unstable fracture patterns involving the anterior and posterior arch (type 3) or those involving the articular surfaces (type 4).

LEVEL OF EVIDENCE

IV (Retrospective cohort study). These slides can be retrieved under Electronic Supplementary Material.

Magnetic resonance tomography for the early detection of occult fractures of the spinal column in patients with ankylosing spondylitis

Purpose

The purpose of this study was to determine the extent to which magnetic resonance imaging (MRI) performed in patients with ankylosing spondylitis (AS) after low- and no-energy trauma leads to an improved diagnosis and, as a result, to a change in the therapeutic strategy.

Methods

All patients with AS, who underwent surgery after minor traumas (low-energy traumas, LETs) and patients without trauma history (NET: no-energy trauma), were retrospectively analysed. The diagnostic and planned surgical procedure was examined initially and again after total spine MRI in patients with persistent and/or new complaints.

Results

One hundred and thirty-six patients with AS after trauma were surgically treated. A total of 92 patients with LETs and 12 patients with NETs were included. After initial diagnostics (CT and X-ray) were performed in 15.4% of the patients with LET or NET (n = 16), we found occult fractures on MRI scans. In ten of these patients (6 LET, 4 NET) in which a previous decision was made to follow conservative therapy, no fracture indication was found on CT or X-ray. Two fracture heights were observed in six patients who experienced LET. However, on X-ray and CT, the fractures were only visible at one height. All fractures were treated surgically with stabilization and decompression if indicated.

Conclusion

Considering the high percentage of our patient population with occult fractures, we recommend supplementing the basic diagnostic procedures with an MRI of the entire spinal column in patients with painful spinal column findings after minor trauma and for those with persistent pain without trauma.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

Which anatomic structures are responsible for the reduction loss after hybrid stabilization of osteoporotic fractures of the thoracolumbar spine?

Introduction

Hybrid stabilization is an accepted therapy strategy for unstable osteoporotic thoracolumbar fractures. However, a moderate reduction loss has been reported and it remains unclear which anatomic structure is responsible for the reduction loss.

Methods

This retrospective study was performed at a level I trauma center. Patients aged 61 and older were stabilized using hybrid stabilization after suffering acute and unstable osteoporotic vertebral body fractures at the thoracolumbar spine. Posterior stabilization was done short-segmental and minimal invasive with cement-augmentation of all pedicle screws. The minimum follow-up has been 2 years. The outcome parameters were the reduction loss and the relative loss of height of both intervertebral discs adjacent to the fractured vertebral body, the fractured vertebral body and a reference disc (intervertebral disc superior of the stabilization) between the postoperative and latest lateral radiographs. Additionally, implant positioning and loosening was analyzed.

Results

29 mainly female (72%) patients (73.3 ± 6.0 years) were included. Fractures consisted of 26 incomplete burst fractures and 3 complete burst fractures of the thoracolumbar junction (Th11 – L2: 86%) and the midlumbar spine. The mean follow-up time was 36 months (range: 24–58 months). The mean reduction loss was 7.7° (range: 1–25). The relative loss of heights of both intervertebral discs adjacent to the fractured vertebral body, the reference disc, and the central vertebral body were significant. Thereby, the relative loss of the superior disc height was significant higher compared to the reference disc. Additionally, only the relative loss of central vertebral body height and reduction loss correlated significantly. There were no signs of implant loosening in any patient.

Conclusions

The mean reduction loss was moderate 3 years after hybrid stabilization of unstable osteoporotic vertebral fractures of the thoracolumbar spine. A significant loss of both adjacent disc heights and the central vertebral body was seen, with the highest loss in the superior adjacent disc significantly outranging the reference disc. The superior adjacent intervertebral disc and the central part of the fractured vertebral body seem to be responsible for the majority of reduction loss.

Kinematics of the Lumbo–Pelvic Complex under Different Loading Conditions

The lumbo-pelvic complex is a highly complex structural system. The current investigation aims to identify the kinematics between interacting bone segments under different loading conditions. A specimen of the lumbo-pelvic complex was obtained from a human body donor and tested in a self-developed test rig. The experimental setup was designed to imitate extension, flexion, right and left lateral bending and axial rotation to the left and to the right, respectively. The vertebra L3 was firmly embedded and load was introduced via hip joints. Using a digital image correlation (DIC) system, the 3D motions of 15 markers at different landmarks were measured for each loadcase under cyclic loading. For each loadcase, the kinematics were analyzed in terms of three-dimensional relative movements between L3 and the sacrum. The usefulness of the experimental technique was demonstrated. It may serve for further biomechanical investigations of relative motion of sacroiliac and vertebral joints and deformation of bony structures.

Hybrid stabilization of unstable osteoporotic thoracolumbar vertebral body fractures: clinical and radiological outcome after a mean of 4 years

PURPOSE

The aim of this study was to evaluate midterm results after hybrid stabilization of unstable osteoporotic fractures of the thoracolumbar junction.

METHODS

This retrospective study was performed at a level I trauma center. A total of 113 patients aged 61 and older were stabilized using hybrid stabilization consisting of short-segmental posterior instrumentation and augmentation of the fractured vertebral body after suffering an unstable osteoporotic vertebral body fracture at the thoracolumbar spine. All patients were treated by hybrid stabilization. The primary outcome parameters were the ODI score and loss of reduction. Secondary radiological outcome parameters were the sagittal alignment parameters.

RESULTS

Seventy-two women and 41 men (74.6 ± 6.8 years) were included. Sixty-nine patients (61%) were re-evaluated after a mean of 48 months. Seventeen patients have died during the follow-up period (15%). A total of five in-patient complications were documented (4.4%). Additionally, 12 patients (17.4%) suffered from further osteoporotic vertebral body fractures affecting vertebral bodies of different levels. The average ODI score at the final follow-up was 29.9 (± 22.0). Thereby, 66.6% of all patients had low to moderate limitations. The average regional sagittal loss of reduction was 7.4% (± 5.6%). Loss of reduction was below 10° in 78% of the patients. There were statistically significant correlations between the loss of reduction and the ODI score, pelvic incidence and latest Cobb angle, and between the ODI scores and the lumbar lordosis.

CONCLUSIONS

The majority of patients had low or moderate limitations and low to moderate reduction loss. Thereby, high loss of reduction correlated directly with inferior outcomes. These slides can be retrieved under Electronic Supplementary Material.

Odontoid fractures in combination with C1 fractures in the elderly treated by combined anterior odontoid and transarticular C1/2 screw fixation

INTRODUCTION

The purpose of this study was to evaluate risk factors of accompanied C1 fractures in elderly patients with type II odontoid fractures (OF) and to analyze the complication rate and the outcomes of patients after combined anterior odontoid and transarticular C1/2 screw fixation (AOTAF).

MATERIALS AND METHODS

The study represents a retrospective case series at a single level-1 trauma center. All elderly patients (≥ 70 years) with acute combination injuries (CI) including type II OF with an accompanied C1 fracture, who were treated by an anterior approach, were included. All postoperative complications were analyzed based on the patient notes. Clinical and radiological controls were performed after 1 year. Main parameters of interest were 1-year mortality rate, pain level, and satisfaction rate after 1 year.

RESULTS

A total of 23 patients were included. The average age was 84.6 years (range 73-94 years). All patients had atlanto-odontoid osteoarthritis (AOO) and all but two patients were injured by low-energy falls. Dysphagia was the most common postoperative complication (26.1%). Surgical revision was necessary in one of these patients due to hematoma. Dysphagia improved in all patients considerably. Loss of follow-up was 21.7%. The 1-year mortality was 21.7% (n = 5). The mean pain level and satisfaction rate was 2.5 (± 0.9) and 7.3 (± 0.7), respectively. After 1 year, no signs of non-union were visible.

CONCLUSIONS

AOO was observed in all patients with CI. The main cause of trauma was a low-energy fall. The pain levels were low to moderate and satisfaction levels were promising 1 year after surgery. Nonetheless, AOTAF is associated with a high rate of postoperative dysphagia, which resolves in the majority of patients due to conservative management.

Comparison of combined posterior and anterior spondylodesis versus hybrid stabilization in unstable burst fractures at the thoracolumbar spine in patients between 60 and 70 years of age

INTRODUCTION

Surgical treatment of unstable burst fractures of the thoracolumbar spine in the elderly population is highly variable with combined posterior and anterior stabilization (CPAS) and posterior augmented stabilization with cementation of the vertebral body (hybrid) being two commonly used techniques. The aim of this study was to compare the clinical and radiographic outcomes of CPAS versus hybrid stabilization for the treatment of unstable burst fractures of the thoracolumbar spine in patients aged between 60 and 70 years.

MATERIALS AND METHODS

A retrospective analysis was performed of all thoracolumbar burst fractures treated surgically in a single level I trauma center between June 2013 and February 2015. Two commonly used strategies of surgical stabilization were compared; the first consisted of initial posterior reduction and bisegmental stabilization, followed by additional anterior spondylodesis (CPAS); the second method comprised a hybrid technique with a posterior cement augmented bisegmental minimally invasive stabilization and kyphoplasty of the fractured vertebral body. Patients were evaluated clinically after a minimum follow-up of 18 months. The primary endpoint was the Oswestry Disability Index (ODI) at the latest follow-up. Secondary parameters of interest were length of in-hospital stay (LIHS), duration of surgery (DS), surgical revisions (SR), pain level (P-VAS), satisfaction level and the SF-36 score (PSC, MSC), the bisegmental postoperative Cobb angle, the reduction loss (RL), and all alignment parameters (pelvic tilt, pelvic incidence, sacral slope, lumbar lordosis, C7 plumb line).

RESULTS

A total of 29 patients were included (17 females, 12 males, mean age 65.6 years ± 3.4 years). The following vertebral bodies were fractured: thoracic level (T) 12: n = 6; lumbar (L) 1: n = 14; L 2: n = 6; L 3: n = 3. CPAS was performed in 10 patients (34%), whereas the hybrid was carried out in 19 patients (66%). There were no statistical significant differences between both study groups regarding age, gender, trauma energy, fracture level, and fracture morphology. The latest follow-up was performed after a mean of 27 months (range 18-53 months). The LIHS between the treatment methods was statistically significant (p < 0.01); CPAS-mean 24 days versus hybrid-mean 12 days. DS was also significantly longer in patients treated with CPAS, 254 versus 95 min for the hybrid group (p < 0.01). No SR were necessary in either group. No significant differences were found regarding the clinical and radiological outcomes between the groups. The mean ODI score was 13.6 in the CPAS patients compared to 10.8 in the hybrid patients without significant differences between the groups. The majority of patients had no (80%) or minor (13%) limitations according to the ODI score. The P-VAS was 2.8 in CPAS and 2.9 in the hybrid group. RL was 7.1° in CPAS and 4.2° in the hybrid group.

CONCLUSIONS

CPAS and hybrid stabilization provide safe and promising short- and middle-term results in patients between 60 and 70 years of age. The majority of patients demonstrated no disability or minimal limitations with either technique. CPAS resulted in prolonged inpatient hospital stays, longer duration of surgery compared to hybrid stabilization without significant differences in clinical and radiological outcome.

Treatment of Injuries to the Subaxial Cervical Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

Expert consensus.

OBJECTIVES

To establish treatment recommendations for subaxial cervical spine injuries based on current literature and the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma.

METHODS

This recommendation summarizes the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma.

RESULTS

Therapeutic goals are a stable, painless cervical spine and protection against secondary neurologic damage while retaining maximum possible motion and spinal profile. The AOSpine classification for subaxial cervical injuries is recommended. The Canadian C-Spine Rule is recommended to decide on the need for imaging. Computed tomography is the favoured modality. Conventional x-ray is preserved for cases lacking a "dangerous mechanism of injury." Magnetic resonance imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and to exclude disco-ligamentous injuries. Computed tomography angiography is recommended in high-grade facet joint injuries or in the presence of vertebra-basilar symptoms. A0-, A1- and A2-injuries are treated conservatively, but have to be monitored for progressive kyphosis. A3 injuries are operated in the majority of cases. A4- and B- and C-type injuries are treated surgically. Most injuries can be treated with anterior plate stabilization and interbody support; A4 fractures need vertebral body replacement. In certain cases, additive or pure posterior instrumentation is needed. Usually, lateral mass screws suffice. A navigation system is advised for pedicle screws from C3 to C6.

CONCLUSIONS

These recommendations provide a framework for the treatment of subaxial cervical spine Injuries. They give advice about diagnostic measures and the therapeutic strategy.

Pyogenic Spondylodiscitis of the Thoracic Spine: Outcome of 1-Stage Posterior Versus 2-Stage Posterior and Anterior Spinal Reconstruction in Adults

OBJECTIVE

The aim of this study was to compare the clinical, radiologic, and functional outcomes of a 1-stage posterior treatment versus a 2-stage posterior-anterior treatment in patients with pyogenic thoracic spondylodiscitis.

METHODS

A 1-stage posterior debridement, stabilization, and fusion with titanium-coated polyetheretherketone (PEEK) or mesh cage through a dorsolateral approach was performed in group A. A 2-stage procedure with initial posterior stabilization and debridement and second-stage fusion with a PEEK cage or mesh cage was performed with an anterior approach in group B. Clinical outcomes included Oswestry Low Back Pain Disability Questionnaire and visual analog scale score. Radiologic outcomes included fusion rate and kyphotic angle correction. Secondary variables included pathogens, complications, blood loss, and operative time.

RESULTS

One-level spondylodiscitis was treated surgically in the thoracic spine of 47 patients: 25 patients in group A and 22 patients in group B. The most frequent segment was T12-L1 (27%). There was a significantly longer operative time and greater blood loss (P > 0.001) in group B. At last follow-up, sagittal profile reconstruction was significantly better (P > 0.05) in group B. Both groups showed similar radiologic results with fusion in 92% of cases. Improved clinical outcomes, pain, and quality of life were achieved in both groups with no significant differences between the 2 groups.

CONCLUSIONS

Better reconstruction of the sagittal profile was achieved in the posterior-anterior-treated group, but this did not affect the clinical outcome. No significant differences were found in the clinical and functional outcomes between the 2 groups. Posterior-anterior combined treatment should be considered in cases of large anterior defects if a posterior reconstruction is inadequate.

Recommendations for Diagnosis and Treatment of Fractures of the Ring of Axis

In a consensus process with four sessions in 2017, the working group “upper cervical spine” of the German Society for Orthopaedics and Trauma Surgery (DGOU) formulated “Therapeutic Recommendations for the Diagnosis and Treatment of Upper Cervical Fractures”, taking their own experience and the current literature into consideration. The following article describes the recommendations for axis ring fractures (traumatic spondylolysis C2). About 19 to 49% of all cervical spine injuries include the axis vertebra. Traumatic spondylolysis of C2 may include potential discoligamentous instability C2/3. The primary aim of the diagnostic process is to detect the injury and to determine potential disco-ligamentous instability C2/3. For classification purposes, the Josten classification or the modified Effendi classification may be used. The Canadian C-spine rule is recommended for clinical screening for C-spine injuries. CT is the preferred imaging modality and an MRI is needed to determine the integrity of the discoligamentous complex C2/3. Conservative treatment is appropriate in case of stable fractures with intact C2/3 motion segment (Josten type 2 and 2). Patients should be closely monitored, in order to detect secondary dislocation as early as possible. Surgical treatment is recommended in cases of primary severe fracture dislocation or discoligamentous instability C2/3 (Josten 3 and 4) and/or secondary fracture dislocation. Anterior cervical decompression and fusion (ACDF) C2/3 is the treatment of choice. However, in case of facet joint luxation C2/3 with looked facet (Josten 4), a primary posterior approach may be necessary.

Use of Simultaneous 18F-FDG PET/MRI for the Detection of Spondylodiskitis

The diagnosis of spondylodiskitis is often challenging. MRI is quite sensitive but lacks specificity, and distinction from erosive osteochondritis is often difficult. We sought to assess the diagnostic value of (18)F-FDG PET combined with MRI (combined (18)F-FDG PET/MRI) in patients with suspected spondylodiskitis and an inconclusive clinical or MRI presentation.

METHODS

In a prospective study, 30 patients with previous inconclusive MRI results and suspected spondylodiskitis underwent combined (18)F-FDG PET/MRI, including precontrast and postcontrast standard spine MRI sequences. The image datasets were evaluated on dedicated workstations by 2 radiology residents and 1 board-certified nuclear medicine physician independently and then in consensus. Because of severe susceptibility artifacts, only 28 of 30 image datasets were evaluable, with a total of 29 regions of suspected spondylodiskitis. SUV ratios (affected disk/reference disk) were determined. The imaging results were compared with histopathology or clinical follow-up as a reference standard and subjected to statistical analysis.

RESULTS

The reference standards identified spondylodiskitis in 12 disks and excluded spondylodiskitis in 17 disks. For MRI alone, the sensitivity was 50%, the specificity was 71%, the positive predictive value was 54%, and the negative predictive value was 67%. Adding the PET data resulted in sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 88%, 86%, and 100%, respectively. In a receiver operating characteristic curve analysis, an SUVmax ratio threshold of 2.1 resulted in 92% sensitivity and 88% specificity (area under the receiver operating characteristic curve, 0.95). Neither the level of C-reactive protein nor the leukocyte count at the time of PET/MRI was related to the reference standard diagnosis of spondylodiskitis.

CONCLUSION

In patients with inconclusive clinical or MRI findings, the use of (18)F-FDG PET/MRI significantly increased diagnostic certainty for the detection of spondylodiskitis.

[How many generalists and how many specialists does orthopedics and traumatology need?]

The training in orthopedic and trauma surgery has changed significantly with the introduction of the new residency program. The contents taught have already been reduced in breadth and the current developments in the outpatient and particularly in the clinical landscape also contribute to increasing specialization. This trend favors structures in which comprehensive medical care for the population in Germany in orthopedic and trauma surgery appears to be endangered and in which the future efforts for e.g. polytraumatised patients need to be questioned. The Young Forum of the German Society for Orthopedics and Traumatology actively accompanies a discussion about the necessity and value of generalists to ensure the level of care in Germany in addition to the specialists.