Morbidity and mortality in cervical spine injuries in the elderly.

BACKGROUND: The aim of our study was to identify the demographics and complications in elderly cervical spine injuries and predictive factors for surgery, complications and mortality. We hypothesized younger healthier patients were more likely to undergo surgical intervention. METHODS: A retrospective review of 225 consecutive patients aged 65 years and over with cervical spine injuries was carried out over a 3-year period. RESULTS: There were 113 males and 112 females with an average of 79.7 years (range 65-98). The most common fracture was C2 peg type (21.8%). Five patients had complete spinal cord injury (2.2%), 25 had incomplete spinal cord injury (11.1%) and 84% were neurologically intact. Fifty-four patients were managed operatively (24%), while 171 patients were managed non-operatively (76%). The operative group had higher rates of pneumonia (odds ratio (OR) 5.3, 95% confidence interval (CI) 2.6-10.7, P < 0.01), cardiac arrhythmia (OR 4.1, 95% CI 1.5-11.2, P < 0.01) and respiratory failure (OR 2.6, 95% CI 1.2-5.5, P < 0.05). There was no difference in mortality between the operative and non-operative group (18.5% and 12.9%, P = 0.3). Patients with complete spinal cord injury had 100% mortality. Significant predictive factors for complications and death were neurological deficits, comorbidities and the presence of other injuries (P < 0.05). Surgery was not predictive for death and the operative group was younger than the non-operative group (P < 0.05). CONCLUSIONS: In the setting of a high complication rate, consideration should be given to palliation in elderly patients with complete spinal cord injury and there must be good rational for surgery.

Occult subaxial cervical disco-ligamentous injuries in computer tomography negative trauma patients.

PURPOSE: Due to lack of cervical clearance consensus in literature and the devastating consequences of missed cervical injuries, Magnetic resonance imaging (MRI) of the neurologically intact symptomatic patient with negative CT scan is frequently done to rule out disco-ligamentous injuries. This study retrospectively evaluates occult disco-ligamentous injuries detected by MRI in patients with no abnormalities detected by modern multi-detector CT scanning and postulates a new theory of ligamentous stability of cervical spine. METHODS: Cervical spine injury patients treated at a spinal trauma referral centre from 2010 to 2013 were retrospectively identified. Available clinical records and radiographic imaging were reviewed to find neurologically intact symptomatic patients with no identifiable acute cervical spine injury on CT scan but MRI evidence of isolated subaxial disco-ligamentous injuries. Patient demographics, injury profile, and treatment details were extracted. Subaxial Cervical Spine Injury Classification (SLIC) and Denis three-column spinal stability theory were adopted to assess stability of injuries. RESULT: 316/566 cervical spinal admissions had CT and MRI scans. 11 (3.5%) CT negative patients were found to have occult discoligamentous injuries on MRI. The average age (51.1 years) was not significantly different to all cervical trauma admissions (p = 0.09). Eight had flexion type and three had extension type injuries. The most common mechanisms were sports and fall on flat surface. The average SLIC score was 3.1. Four patients were classified as having unstable or potentially unstable injuries (two patients each) and three of these patients were surgically managed. Subtle CT changes to indicate discoligamentous injury could be retrospectively identified in all four of these patients. CONCLUSION: CT scans alone may be inadequate for clearing occult disco-ligamentous injuries of the subaxial cervical spine in trauma. Denis three-column stability theory may be beneficial in determining stability and guiding treatment along with the SLIC system for occult discoligamentous injuries of the subaxial cervical spine.

Subaxial injury classification scoring system treatment recommendations: external agreement study based on retrospective review of 185 patients.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To test validity of subaxial injury classification (SLIC) treatment recommendations. SUMMARY OF BACKGROUND DATA: Although SLIC has been tested for reliability, external studies that test the validity of its treatment recommendations are lacking. METHODS: The SLIC score was determined by reviewing imaging studies and clinical records in a consecutive series of 185 patients with subaxial cervical spine trauma presenting to a level 1 spinal injury referral center. Details including attending surgeon responsible for treatment decision, treatment received, and surgical approach were collected. RESULTS: Treatment received matched SLIC guidelines in 93.6% nonsurgically managed patients and 96.3% surgically managed patients. The mean SLIC score of the surgically treated group of patients was significantly higher than that of the nonsurgical group (7.14 vs. 2.22; P<0.001). Sixty-six patients had a SLIC score of 3 or less, and 94% of them were nonsurgically managed (P<0.001). One hundred two patients had a SLIC score of 5 or more, and 95% of them were surgically managed (P<0.001). Seventeen patients had a SLIC score of 4, and 65% were nonsurgically managed (P=0.032). Injury morphology scores were not predictive of surgical approach. Increasing SLIC scores correlated with increasing complexity of treatment (r=0.77; P<0.001). The distribution of patients with regard to severity of injuries and treatment delivered by the 7 spinal surgeons was comparable. The past practice of these 7 fellowship-trained spine surgeons was individually in agreement with SLIC treatment recommendations. CONCLUSION: Our past practice reflects SLIC treatment recommendations for nonsurgical treatment of patients with SLIC scores of 3 or less and surgical treatment of patients with SLIC scores of 5 or more. The use of SLIC as an ordinal severity scale is validated as increasing SLIC scores correlated with increasing complexity of treatment. The injury morphology score did not predict a surgical approach. Significantly higher numbers of patients with a SLIC score of 4 were treated nonsurgically. LEVEL OF EVIDENCE: 3.

Fusion risk score: evaluating baseline risk in thoracic and lumbar fusion surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The fusion risk score (FRS) is introduced to assess baseline risk of spine fusion surgery preoperatively. An objective method of stratifying risk allows the surgeon to control risk through tailoring intervention and explain differences in complication profile in high-complexity practice. SUMMARY OF BACKGROUND DATA: Research has identified an elevated risk of serious complications in performing spine fusion surgery in the elderly, yet the rate of such surgery continues to increase. A range of comorbidities and the surgical factors are demonstrated predictors of perioperative risk. METHODS: Retrospective review was made of 364 consecutive fusion surgical procedures in patients older than 65 years in an 18-month period. Logistic regression analysis was performed to identify factors predictive for the occurrence of perioperative events. The predictive variables were incorporated in a weighted fashion into the FRS scaled from 1 to 20. Patient demographics and comorbidities were incorporated into the FRS patient score (maximum 10) and surgical approach, levels, and osteotomies into the FRS procedure score (maximum 10). RESULTS: Multivariate analysis demonstrated chronic kidney disease (odds ratio [OR] = 5.3, 95% confidence interval [CI]: 1.5-18.6, P = 0.008), chronic obstructive pulmonary disease (OR = 5.3, 95% CI: 2.0-14.2, P < 0.001), ischemic heart disease (OR = 4.1, 95% CI: 2.0-8.4, P < 0.001), an open anterior approach (OR = 3.6, 95% CI: 1.4-9.3, P = 0.010), diabetes (OR = 3.0, 95% CI: 1.4-6.4, P = 0.004), previous spinal surgery at the same site (OR = 2.6, 95% CI: 1.3-4.9, P = 0.005), age (OR = 1.07, 95% CI: 1.01-1.13, P = 0.019), and the number of motion segments fused (P = 0.049) to be predictive of perioperative events. When applied, the FRS was highly predictive of perioperative events, intensive care unit admission, operative time, blood loss, and length of stay (all P < 0.0001). A score over threshold 9 carries a greater than 50% risk of perioperative events. CONCLUSION: The FRS predicts the risk of complications after spine fusion surgery on the basis of patient and surgery characteristics. It also predicts the risk of intensive care unit admission and correlates with operative time, blood loss, and postoperative length of stay. By balancing the FRS procedure score to the individual FRS patient score, the surgeon can quantify and control perioperative risk.

MRI-negative, bone scintigram-positive in early osteonecrosis of the knees.

Nontraumatic avascular necrosis (AVN) of bone is a well-reported complication of glucocorticoid therapy for immunologic and malignant disease. We present the case of a 13-year-old girl with no history of trauma who presented with a 5-day history of increasing pain in both knees after cord blood transplantation for acute lymphoblastic leukemia. Plain film and magnetic resonance imaging (MRI) were reported as normal. Bone scintigraphy revealed evidence of bilateral avascular necrosis in the distal femora. MRI subsequently became abnormal several weeks later. The case illustrates the natural history of AVN, in which changes that are detected by MRI can take several weeks to develop. The scintigraphic findings influenced early management of the condition.

Retrograde nailing versus fixed-angle blade plating for supracondylar femoral fractures: a randomized controlled trial.

BACKGROUND: A variety of devices have been used in the treatment of supracondylar femoral fractures. The condylar blade plate relies on the principles of open reduction, absolute stability and interfragmentary compression to achieve union. The technique of retrograde nailing uses indirect reduction of the metaphyseal fracture component, offering relative stability and a less invasive approach. Randomized comparison of these common methods of fixation has not been reported. METHODS: Twenty-two patients with 23 supracondylar femur fractures were recruited from two regional trauma centres over a 26-month period and randomized to receive either a retrograde intramedullary nail fixation (IM group, 12 fractures) or a fixed-angle blade plate fixation (BP group, 11 fractures). The groups were followed for 12-36 months. The primary outcome measures were revision surgery and general health. RESULTS: Three patients in the IM group required revision surgery for the removal of implant components. No reoperations occurred in the BP group. There was a trend towards greater pain in the IM group, although there was no statistically significant difference in the scores for any of the SF-36 domains. CONCLUSION: Both distal femoral nailing and blade plating give good outcomes. There is a trend for patients undergoing retrograde nailing to complain of more pain and to require revision surgery for removal of implants.