Percutaneous vertebral augmentation for acute traumatic vertebral Fractures: A TQIP database study

Patients with vertebral fractures may be treated with percutaneous vertebroplasty (VP) and kyphoplasty (KP) for pain relief. Few studies examine the use of VP and KP in the setting of an acute trauma. In this study, we describe the current use of VP/KP in patients with acute traumatic vertebral fractures. All patients in the ACS Trauma Quality Improvement Program (TQIP) 2016 National Trauma Databank with severe spine injury (spine AIS ≥ 3) met inclusion criteria, including patients who underwent PVA. Logistic regression was used to assess patient and hospital factors associated with PVA; odds ratios and 95 % confidence intervals are reported. 20,769 patients met inclusion criteria and 406 patients received PVA. Patients aged 50 or older were up to 6.73 (2.45 - 27.88) times more likely to receive PVA compared to younger age groups and women compared to men (1.55 [1.23-1.95]). Hospitals with a Level II trauma center and with 401-600 beds were more likely to perform PVA (2.07 [1.51-2.83]) and (1.82 [1.04-3.34]) respectively. African American patients (0.41 [0.19-0.77]), isolated trauma (0.64 [0.42-0.96]), neurosurgeon group size > 6 (0.47 [0.30-0.74]), orthopedic group size > 10, and hospitals in the Northeastern and Western regions of the U.S. (0.33 [0.21-0.51] and 0.46 [0.32-0.64]) were less likely to be associated with PVA. Vertebroplasty and kyphoplasty use for acute traumatic vertebral fractures significantly varied across major trauma centers in the United States by multiple patient, hospital, and surgeon demographics. Regional and institutional practice patterns play an important role in the use of these procedures.

Epidemiology of primary malignant non-osseous spinal tumors in the United States

BACKGROUND CONTEXT

Primary malignant non-osseous spinal tumors are relatively rare and this has led to a paucity of studies specifically examining the epidemiology of malignant spinal tumors.

PURPOSE

To provide an updated and more comprehensive study examining the epidemiology and relative survival of these rare tumors.

STUDY DESIGN/SETTING

Data was retrospectively acquired from the Central Brain Tumor Registry of the United States (CBTRUS).

PATIENT SAMPLE

Primary malignant non-osseous spinal tumor cases diagnosed between 2000 and 2017 in the United States.

OUTCOME MEASURES

Incidence rates (IRs), relative survival rates, and hazard ratios (HR) were measured.

METHODS

IRs were calculated only for histologically-confirmed cases between 2000 and 2017. Relative survival estimates were calculated from survival information on malignant spinal tumors between 2001 and 2016 for death from any cause. Multivariable Cox proportional hazards regression models were constructed to control for age, sex, race, and ethnicity.

RESULTS

From 2000 to 2017, approximately 587 new cases of malignant non-osseous spinal tumors were diagnosed every year in the United States. The overall IR was 0.178 per 100,000 persons. Ependymomas were the most commonly diagnosed tumor in all age groups. The 10-year relative survival rates were 94.1%, 62.1%, 62.0%, and 13.3% for ependymomas, lymphomas, diffuse astrocytomas, and high-grade astrocytomas, respectively. Females have a significantly lower risk of death as compared with males for ependymomas (HR: 0.74, p<.001) and diffuse astrocytomas (HR: 0.70, p=.005). African-Americans have a significantly higher risk of death compared with Caucasians when diagnosed with ependymomas (HR: 1.52, p=.009) or lymphomas (HR: 1.55, p=.009).

CONCLUSION

Primary malignant non-osseous spinal tumors are primarily diagnosed in adulthood or late adulthood. Ependymal tumors are the most commonly diagnosed primary malignant non-osseous spinal tumors and have the highest 10-year relative survival rates. High-grade astrocytomas are rare and portend the worst prognosis.

Failure of Conservatively Managed Traumatic Vertebral Compression Fractures: A Systematic Review

BACKGROUND

Most vertebral compression fractures (VCFs) are successfully managed conservatively, however, some patients fail conservative management and require further surgical treatment. Here, we identify significant variables that contribute to progressive vertebral collapse in non-operative treatment of traumatic VCFs.

METHODS

A systematic review using PRISMA guidelines identified original research articles of conservatively managed VCF secondary to trauma from inception to September 2021. Articles with patients treated with initial non-operative therapy, AO-Type A0/A1/A2 fractures, risk factor analysis, >10 patients, and vertebral fracture secondary to trauma were included. Articles including pediatric patients, burst fractures or AO-Type A3/A4 fractures, vertebral fractures secondary to neoplasm or infectious disease, and operative versus non-operative treatment comparative studies were excluded. Failure of non-operative treatment was defined as salvage surgery/vertebral augmentation, progressive kyphosis, chronic pain, or functional disability.

RESULTS

3,877 articles were identified, and six articles were included. 582 patients had conservatively managed thoracolumbar VCFs. 102 patients had reported treatment failure (17.5%). Of the 102 treatment failures, 37 (36.3%) were due to subsequent VCF, 33 (32.4%) to back pain or functional disability at follow-up, and 32 (31.4%) were to increased compression rate or kyphotic deformity at follow-up. Two of the six studies (33.3%) demonstrated prior VCF as a significant variable. Age, lumbar bone mineral density, segmental Cobb angle, and vertebral height loss were each described as a significant factor in one of the six studies (16.7%).

CONCLUSION

Identifying patients who are at risk for treatment failure may help select individuals that would benefit from close clinical follow-up or early surgical/procedural intervention.

Evaluation of nonaccidental trauma in infants presenting with skull fractures: a retrospective review

OBJECTIVE

Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk.

METHODS

A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk.

RESULTS

A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup).

CONCLUSIONS

Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.