Economic implication of osteoporotic spine disease: cost to society

The costs of vertebral fractures are less well defined than the costs of hip fractures. Large studies are urgently needed. From the data that exist, vertebral fractures have a higher cost than previously expected: for hospitalized fractures in a US study, USD 10 000 per year without rehabilitation costs, for all clinical fractures USD 2000 the first year, and in a Swedish study slightly more. These new data on the cost of vertebral fractures will have an impact on health economy calculations. In the future it may be be cost-effective only to prevent vertebral fractures.

Fracture dislocations of the cervical spine: a review of 106 conservatively and operatively treated patients

We compared clinical outcomes following conservative treatment of subaxial fracture dislocations of the cervical spine and posterior fusion using bone grafts and interspinous Roger's wiring (Bohlman modification). We reviewed 106 patients: 51 were treated primarily surgically, and 55 treated conservatively served as historical controls. Those patients who neurologically recovered at least one Frankel grade had on average less displacement on discharge (1.3 mm vs 3.1 mm, p=0.04). Although anatomical outcomes were better in the operatively treated group (1.6 mm vs 2.9 mm displacement at end of follow-up, p=0.001), there was no difference in neurological recovery. Late neck pain correlated with residual displacement ( p=0.04) and was more common in the conservatively treated patients ( p=0.01). Time in hospital was shorter in the group with posterior fusions, and complication rates were similar to those found after conservative treatment. A significant number of the conservatively treated patients developed kyphotic deformity, and 29% needed later surgery because of chronic instability or unacceptable anatomical results.

AO-classification of thoracic and lumbar fractures--reproducibility utilizing radiographs and clinical information

This study was designed to assess the inter-observer reliability and intra-observer reproducibility of standard radiographic evaluation of 150 thoraco-lumbar fractures using the AO-classification. The influence of clinical information on agreement levels was also evaluated. Six observers (two junior and four senior residents) evaluated the radiographic images. The injuries were classified by each observer as either type A, B or C according to the AO-classification system and the levels of agreement were documented. After 3 months the injuries were again classified with the addition of the clinical findings of each patient and the level of agreement evaluated. The level of agreement was measured using Cohen's kappa-test. The overall inter-observer agreement was rated as fair (0.291) in the first session and moderate (0.403) in the second. Intra-observer values ranged from slight (0.181) to moderate (0.488). The increased level of agreement in the second session was attributed to the value of additional clinical information, the learning curve of the junior residents and the simplicity of the classification.

Management of cervical fractures in ankylosing spondylitis: anterior, posterior or combined approach?

INTRODUCTION

Ankylosing spondylitis (AS) can lead to an increased risk of cervical fractures.

SOURCES OF DATA

A systematic review was undertaken using the keywords 'ankylosing spondylitis', 'spine fractures', 'cervical fractures', 'surgery' and 'postoperative outcomes' on Medline, Pubmed, Google Scholar, Ovid and Embase, and the quality of the studies included was evaluated according to the Coleman Methodology Score.

AREAS OF AGREEMENT

Surgery ameliorates neurological function in patients with unstable AS-related cervical fractures. The combined anterior/posterior and the posterior approaches are more effective than the anterior approach.

AREAS OF CONTROVERSY

The optimal approach, anterior, posterior or combined anterior/posterior, for the management of AS related cervical fractures has not been defined.

GROWING POINTS

Open reduction and internal fixation allows avoiding worsening and enhances neurological function in AS patients with cervical fractures.

AREAS TIMELY FOR DEVELOPING RESEARCH

Adequately powered randomized trials with appropriate subjective and objective outcome measures are necessary to reach definitive conclusions.

Balloon Kyphoplasty in the Treatment of Neoplastic Spine Lesions: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

To assess the efficacy of kyphoplasty in controlling pain and improving quality of life in oncologic patients with metastatic spinal disease and pathologic compression fractures of the spine.

METHODS

A literature search through medical database was conducted (using PubMed, EMBASE, Cochrane, and LILACS) for randomized controlled trials comparing balloon kyphoplasty versus the traditional treatment for compression fractures of the spine due to metastatic disease. Two investigators independently assessed all titles and abstracts to select potential articles to be included. Inclusion criteria consisted of randomized controlled trials involving patients with pathologic compression fractures due to spinal metastasis or multiple myeloma treated with balloon kyphoplasty procedure as one of the study interventions, while the control group was any other treatment modality. The risk of bias in individual studies was assessed.

RESULTS

Two studies, with a combined total of 181 patients, met inclusion criteria. Because of data heterogeneity, the meta-analysis was not possible, and individual analysis of studies was performed. There is moderate evidence that patients treated with balloon kyphoplasty displayed better scores for pain (Numeric Rating Scale), disability (Roland-Morris Disability Questionnaire), quality of life (Short Form-36 Health Survey), and functional status (Karnofsky Performance Status) compared with those undergoing the conventional treatment. Patients treated with kyphoplasty also have better recovery of vertebral height.

CONCLUSIONS

This study concluded that balloon kyphoplasty could be considered as an early treatment option for patients with symptomatic neoplastic spinal disease, although further randomized clinical trials should be performed for improvement of the quality of evidence.

The use of minimally invasive surgery in spine trauma: a review of concepts

Traumatic injuries to the spine can be common in the setting of blunt trauma and delayed diagnosis can have a deleterious effect on patients' health. The goals of treatment in managing spine trauma are prevention of neurological injury, providing stability to the spine, and correcting post-traumatic deformity. Minimally invasive spine surgery (MISS) techniques are an alternative to open spine surgery for treatment of spine fractures. MISS is also a viable treatment in the setting of damage control orthopedics, when patients with multiple traumatic injuries may be unable to tolerate a traditional open approach. MISS techniques have been used in the treatment of unstable fractures with or without spinal cord injury, flexion and extension-distraction injuries, and unstable sacral fractures. Traditional open surgeries have been associated with increased blood loss, longer operative times, and a higher risk for surgical site infection (SSI). MISS techniques have the potential to reduce open approach-associated morbidity, and improve postoperative care and rehabilitation. MISS techniques for spine trauma are an indispensable option in the treatment armamentarium of spine surgeons.

Factors predicting long-term outcome after short-segment posterior fixation for traumatic thoracolumbar fractures

Background:

The “gold standard” for instrumentation of unstable thoracolumbar fracture-dislocations is pedicle screw and rod fixation. Although traditional treatment supports long-segment posterior fixation (LSPF), more recent studies show short-segment posterior fixation (SSPF) may be effective, but incur higher failure rates. Here, we evaluated the effectiveness of SSPF in the management of unstable thoracolumbar injuries and analyzed the factors impacting long-term outcomes.

Methods:

In this retrospective analysis of 91 patients with thoracolumbar fractures managed with SSPF alone, we assessed the clinical and radiological parameters at preoperative, postoperative, and follow-up intervals along with reasons for failures of SSPF.

Results:

We analyzed 91 patients (mean age: 33.5 years; Male: Female = 50:41) with thoracolumbar fractures treated with SSPF over a median follow-up period of 30 months. SSPF failures were observed in 26 of 91 (28.6%) patients; the median time to implant failure was 17 months. On univariate analysis, statistically significant factors contributing to failure of SSPF included the presence of a burst fracture, a preoperative LSC (load-sharing classification) score >6, and translation/dislocation. With multinomial regression analysis, the only factor predictive for SSPF failure was the patients' postoperative ambulatory status.

Conclusion:

Patients with thoracolumbar facture dislocations, subjected to axial spinal loading postoperatively, should not be considered for SSPF alone. The following factors also contributed to SSPF failures: a burst fracture, a preoperative LSC score of >6, and/or presence of transverse dislocation.

Early Versus Late Spine Surgery in Severely Injured Patients-Which Is the Appropriate Timing for Surgery?

STUDY DESIGN

Retrospective cohort study conducted at tertiary spinal trauma referral center.

OBJECTIVE

We aimed to determine if early definitive management of spine fractures in patients admitted to the Intensive Care Unit (ICU) shortens the intubation time and the length of stay (LOS), without increasing mortality.

METHODS

The medical records of all patients admitted to the ICU and submitted to surgical stabilization of spine fractures were reviewed over a 10-year period. Time to surgery, number of fractured vertebrae, degree of neurological injury, Simplified Acute Physiology Score (SAPS II), ASA score and associated trauma were evaluated. Surgeries performed on the first 72 hours after trauma were defined as "early surgeries." Intubation time, LOS on ICU, overall LOS and mortality rate were compared between patients operated early and late.

RESULTS

Fifty patients were included, 21 with cervical fractures, 23 thoracic and 6 lumbar. Baseline characteristics did not differ between patients in both groups. Patients with early surgical stabilization had significantly shorter intubation time, ICU-LOS and overall LOS, with no differences in terms of mortality rate. After multivariate adjustments overall LOS was significantly shorter in patients operated earlier.

CONCLUSIONS

Early spinal stabilization (<72 hours) of severely injured patients is beneficial and shortens the intubation time, ICU-LOS and overall LOS, with no differences in terms of mortality rate. Although some patients may require a delay in treatment due to necessary medical stabilization, every reasonable effort should be made to treat patients with unstable spinal fractures as early as possible.

LEVEL OF EVIDENCE OF THE STUDY

Level III.

Traumatic L5 Posterolateral Spondyloptosis: A Case Report and Review of the Literature

Traumatic retrolisthesis of the lumbar spine is a rare clinical entity. Only a few case reports have shown retrolisthesis of the fractured fragment over the inferior vertebral body. Fracture dislocations of the spine are unstable injuries that require operative fixation to restore alignment and prevent progressive deformity.

We present the case of a traumatic L5-S1 fracture dislocation with retrolisthesis of the L5 vertebral body over the superior aspect of S1 managed with anterior, middle, and posterior column reconstruction. The patient presented with paraplegia and bowel and bladder incontinence.

Retrolisthesis fracture dislocations injuries are rare, and as such, there are no guidelines regarding their management. In our case, we performed an L5 vertebrectomy with anterior, middle, and posterior column reconstruction via a posterior approach using a lumbosacral-pelvic construct. The patient did not regain function in his distal lower extremities postoperatively.

Artificial Intelligence-Assisted Detection of Osteoporotic Vertebral Fractures on Lateral Chest Radiographs in Post-Menopausal Women

Osteoporotic vertebral fractures (OVFs) are often not reported by radiologists on routine chest radiographs. This study aims to investigate the clinical value of a newly developed artificial intelligence (AI) tool, Ofeye 1.0, for automated detection of OVFs on lateral chest radiographs in post-menopausal women (>60 years) who were referred to undergo chest x-rays for other reasons. A total of 510 de-identified lateral chest radiographs from three clinical sites were retrieved and analysed using the Ofeye 1.0 tool. These images were then reviewed by a consultant radiologist with findings serving as the reference standard for determining the diagnostic performance of the AI tool for the detection of OVFs. Of all the original radiologist reports, missed OVFs were found in 28.8% of images but were detected using the AI tool. The AI tool demonstrated high specificity of 92.8% (95% CI: 89.6, 95.2%), moderate accuracy of 80.3% (95% CI: 76.3, 80.4%), positive predictive value (PPV) of 73.7% (95% CI: 65.2, 80.8%), and negative predictive value (NPV) of 81.5% (95% CI: 79, 83.8%), but low sensitivity of 49% (95% CI: 40.7, 57.3%). The AI tool showed improved sensitivity compared with the original radiologist reports, which was 20.8% (95% CI: 14.5, 28.4). The new AI tool can be used as a complementary tool in routine diagnostic reports for the reduction in missed OVFs in elderly women.

Temporary spanning internal fixation for management of complex upper cervical spine fractures

Introduction:

Fractures of the upper cervical spine are often but not always amenable to either internal fixation or conservative management using a rigid cervical collar. For all other fractures in this area, management with a halo-vest orthosis is indicated, but it also has limitations. Here, we present an operative alternative to the halo-vest orthosis that provides more secure stability and less complications.

Methods:

Three patients presented to our hospital with atypical fractures of C1 and C2 and were given the choice of either a halo-vest orthosis or secure internal fixation without fusion and accepted the latter. Internal fixation without fusion from occiput to the subaxial spine was performed for all three and then removed-6 months later -after radiologic confirmation of healing.

Results:

All three patients underwent the procedure successfully and achieved and maintained acceptable alignment. Range of motion was preserved, and no intermediate-term issues were observed.

Conclusion:

Spanning internal fixation provides a safe and effective technique in the management of complex upper cervical spine injuries without the drawbacks of using a halo-vest orthosis.

[Recovery form of the vertebral body in a transpedicular fixation at spine fractures associated with osteoporosis]

We analyzed the correction indexes of posttraumatic deformation in 27 patients aged 61-76 years (62,9±1,4 years), when using an osteoplasty and transpedicular of fixation in respect of fractures of bodies vertebras of the thoracic and lumbar localization, associated with osteoporosis. Indicators of posttraumatic deformation the wedging index (WI) and the segmental kyphosis (SK) decreased at all patients. At the same time the minimally invasive (transcutaneous) operation allowed to achieve recovery of the lost anatomy and does not concede to results of open intervention. In group of patients with compression fractures decreased WI and SK, and in group with burst nature of damage only WI authentically decreased. Both indicators of deformation decreased at patients with T-criterion more than -3 SD, and only WI authentically decreased at patients with more expressed decrease in mineral density (T-criterion >-3). The received results show recovery of the lost anatomy, at the same time extent of correction depends on character fractures and the number of bone masses.

Twenty year outcomes following short-segment posterior instrumentation and fusion for thoracolumbar burst fractures: A retrospective observational study

This study reviews the long-term efficacy of short-segment posterior instrumentation and fusion (SSPIF) in treating thoracolumbar burst fractures. Authors retrospectively reviewed the radiographic results of single-level thoracolumbar burst fractures treated by SSPIF. Vertebral body height and wedge angles were measured on the preoperative, postoperative, and follow-up radiographic images. The degree of pain and work ability was measured using the Denis scale. The analysis consisted of 12 patients with a mean age of 39.7 years (range 21-60) and a mean follow-up of 225.6 ± 20.3 months. There were significant differences among the wedge angles at preoperative and other periods of time, but there was no significant difference between the early postoperative and all other time periods afterwards (P < .001, P = .567, P = .937, P = .879). SSPIF effectively restored the anterior and middle vertebral body height and wedge angle deformities, and the improvement was maintained for almost 20 years after the surgery. Therefore, SSPIF is a safe and effective modality of treatment for thoracolumbar burst fractures.

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.

The sequence of the treatment of combined fractures of the pelvis, spine, and extremities in polytraumatized patients

'Damage control' is the therapeutic strategy in the treatment of polytraumatized patients and aims at securing vital functions and controlling bleeding with a favorable effect on the post-traumatic immune response. The post-traumatic immune dysfunction is based on a disturbed balance between immunostimulatory and anti-inflammatory mechanisms. The extent of the immunological 'second hit' can be limited by delaying deferable surgical therapies until organ stabilization has been achieved by the treating surgeon. Pelvic sling is easy to apply and noninvasive with effective pelvic reduction. Pelvic angiography vs pelvic packing are not antagonistic, but rather should be considered as complementary methods. Operating as early as possible on unstable spinal injuries with confirmed or suspected neurological deficits by decompression and stabilization with a dorsal internal fixator. Dislocations, unstable or open fracture, vascular involvement, and compartment syndrome are considered emergency indications. In extremity fracture treatment, primary definitive osteosynthesis is often dispensed with and instead, temporary stabilization with an external fixator is performed.