The incidence and risk factors for unplanned readmission within 90 days after surgical treatment of spinal fractures.

INTRODUCTION: Unplanned readmissions after spine surgery are undesired, and cause significant functional, and financial distress to the patients and healthcare system. Though critical, knowledge about readmissions after surgery for traumatic spinal injuries (TSI) is scarce and under-evaluated. METHODS: Consecutive patients surgically treated for TSI and who had unplanned readmission within 90 days post-discharge were studied. Peri-operative demographic and surgical variables, surgical treatment, level of injury, delay in surgery, ASIA score, other organ injuries, peri-operative complications, smoking, ICU stay, co-morbidity, and the length of hospital stay were studied and correlated with the causes for readmission. RESULTS: Among 884 patients, 4.98% (n = 44) had unplanned readmissions within 90 days of discharge. Notably, 50% (n = 22) patients were readmitted within the first 30 days. The common causes of readmissions were urinary tract related problems (27%, n = 12), pressure ulcers (20.4%, n = 9), respiratory problems (13.6%, n = 6), surgical wound related problems (14%, n = 7,) limb injuries (11.4%, n = 5), and others (11%, n = 5). The total beds lost secondary to readmissions was 314 days, and the mean bed-days lost per patient was 7.2 ± 5.1. Thirteen peri-operative risk factors were associated with unplanned readmissions, among which, smoking (OR 2.2), diabetes (OR 2.4), and pressure sore during index admission (OR 16.7) were strong independent predictors. CONCLUSION: The incidence of unplanned readmissions after TSI was 5%, which was similar to elective spine surgeries but the causes and risk factors are different. Non-surgical complications related to urinary tract, respiratory care and pressure sores were the most common causes. Pre-operative smoking status, diabetes mellitus and pressure sores noted in the index admission were important independent risk factors.

Do all Isler's type sacral fractures necessarily require surgical fixation?

INTRODUCTION: A unilateral vertical sacral fracture that exits medial or through the L5-S1 facet joint is considered to affect the lumbo-sacral integrity, and it is denoted as an indication for surgical fixation. However, no studies have analysed the outcomes after non-operative treatment of such injuries. METHODS: A retrospective review of all sacral fractures treated over a five-year period was performed to identify patients with Isler's fractures. Demographic and surgical data, all pre-operative and follow-up images (AP radiographs, CT images), functional outcomes based on VAS, SF-12 and return to work were documented for all patients. RESULTS: The incidence of Isler's fractures was 18% (34/181). The mean age was 42.12 ± 16.3 years. As per Isler's subtypes, fractures passed through L5-S1 joint in 13 (Type 2a) and medial to it in 15 (Type 2b), fractures of L5 or S1 facets in 3 (Type 1), Type 3 injuries were not detected. All patients had concomitant pelvic ring injuries. Sixteen fractures (neurologically intact, < 1 cm displacement, anterior ring stable, no facetal dislocation) were treated non-operatively while 18 patients underwent surgery. At a mean of 15.2 months, the fractures had united in all patients radiographically. The mean VAS score for low back pain (1.4 ± 1.01 vs 1.5 ± 0.79), ability to squat and sit cross-legged (56.3% vs 55.6%) and return to work (68.8% vs 66.7%), and Majeed score (77.2 ± 3.9 vs 79.6 ± 4.1) were similar in non-surgical and surgical groups, respectively, at the final follow-up. CONCLUSION: Our study indicates that 47% of Isler's fractures were mechanically stable and could be effectively treated non-operatively with good radiological and functional outcomes.

Advanced disc degeneration, bi-planar instability and pathways of peri-discal gas suffusion contribute to pathogenesis of intradiscal vacuum phenomenon.

PURPOSE: Intradiscal vacuum phenomenon (IDVP), despite being ubiquitous, is poorly understood. The dynamic passage of peri-discal gases into the degenerated disc is a commonly accepted theory. But the reasons behind its selective appearance in some discs are unevaluated. METHODS: 721 patients with chronic low back pain ± radiculopathy, were evaluated with AP and flexion-extension lateral radiographs and MRI. IDVP was classified based on its morphology and location. Radiographic parameters including sagittal translation, sagittal angulation, lateral listhesis, eccentric disc collapse, Pfirrmann's grade, disc height, Modic changes, anterior longitudinal ligament status, and primary spinal disease at the level of IDVP was analyzed. RESULTS: IDVP was present in 342 patients, and they had a higher mean age (57.2 ± 12.5 years) than controls (p < 0.001). Eccentric disc space narrowing (26.5% vs 1.3%, p < 0.01), coronal listhesis (7.83% vs 1.1%, p < 0.001), sagittal angular motion difference (11.3 ± 4.6°, p < 0.001), higher mean disc degeneration (4.36 ± 0.69, p < 0.001), ALL disruption (30.3% vs 2.2%, p < 0.001) and Modic changes (88.6% vs 17.5%, p < 0.001) were significantly higher in IDVP discs (vs. non-IDVP). Binary logistic regression analysis indicated sagittal angular motion difference was the most predictive factor. IDVP was classified into three types-dense type (47.5%), linear (29.5%), dot type (23%). Dense type matched radiological correlations of IDVP while dot types behaved like non-IDVP discs. CONCLUSION: Modic disc-endplate contacts, ALL disruption and coronal translation could be pathways for the passage of peri-discal gases into the degenerated disc. In the pathogenesis of IDVP, advanced disc degeneration, the presence of pathways of gas transfer and angular/coronal instability seem to play complementary roles.

Lumbar artery pseudoaneurysm: a rare case of delayed onset incomplete cauda equina syndrome following transforaminal lumbar interbody fusion.

BACKGROUND: Cauda equina syndrome following transforaminal lumbar interbody fusion (TLIF) is very rare, and the causes implicated include inadequate decompression, retained disc fragments, epidural haematoma, gel foams, fat pad grafts, retained sponges, intradural masses and ischaemia of conus. This is a rare case report of pseudoaneurysm of dorsal branch of lumbar artery presenting with delayed onset incomplete cauda equina syndrome following TLIF. OBJECTIVE: To describe the very rare case of lumbar artery pseudoaneurysm causing delayed onset incomplete cauda equina syndrome following TLIF and its management with endovascular embolisation. METHOD: An 80-year-old female presented with incomplete cauda equina syndrome on 14th post-operative day following TLIF. On evaluation, computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed haematoma with heterogeneous signal intensity, which was pulsatile in ultrasonogram. Doppler and contrast-enhanced CT revealed pseudoaneurysm from posterior branch of left lumbar L4 artery, which was managed with endovascular embolisation. RESULT: After endovascular embolisation, the patient had immediate relief from radiating pain in left lower limb and regained full motor power and perianal sensation at the end of 3 weeks. Post-procedure ultrasonography done on the tenth day revealed complete resolution of the pseudoaneurysm. CONCLUSION: This case presentation shows the necessity of diagnosing epidural haematomas due to vascular aneurysm in patients with post-operative radiculopathy and neurodeficit and the effectiveness of endovascular embolisation in treating such a threatening condition.

Diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies.

INTRODUCTION: Conventional diagnosis of spinal tuberculosis (TB) is based on a combination of clinical features, laboratory tests and imaging studies, since none of these individual diagnostic features are confirmatory. Despite the high sensitivity of MRI findings in evaluating spinal infections, its efficacy in diagnosing spinal TB is less emphasized and remains unvalidated through tissue studies. METHODOLOGY: We reviewed consecutive patients evaluated for spondylodiscitis with documented clinical findings, MRI spine, and tissue analysis for histopathology, TB culture and genetic TB PCR. MRI features documented include location, contiguous/non-contiguous skip lesions, para/intraosseous abscess, subligamentous spread, vertebral collapse, abscess size/wall, disc involvement, end plate erosion and epidural abscess. Based on the results, patients were divided into two groups-CONFIRMED TB with positive culture/histopathology and NON-TB. The efficacy of MRI findings in accurately diagnosing spinal TB was compared between the two groups. RESULTS: Among 150 patients, 79 patients were TB positive, and 71 were TB negative. Three MRI parameters showed significant differences (p < 0.001), namely subligamentous spread (67/79, 84.8%), vertebral collapse > 50% (55/79, 69.6%) and large abscess collection with thin abscess wall (72/79, 91.1%) being strongly predictive of TB. Combination of MRI findings had a higher predictive value. 97.5% of TB positive patients had at least one of these three MRI features, 89.8% patients had any two and 58.2% had all three. CONCLUSION: Our study validated different MRI findings with tissue studies and showed spinal infections with large abscess with thin wall, subligamentous spread of abscess and vertebral collapse were highly suggestive of spinal tuberculosis. These slides can be retrieved under Electronic Supplementary Material.

Modified anterior-only reduction and fixation for traumatic cervical facet dislocation (AO type C injuries).

PURPOSE: Surgical reduction of uni and bi-facetal dislocations of the cervical spine (AO type C injuries) can be performed by posterior, anterior or combined approaches. Ease of access, low infection rates and less risks of neurological worsening has popularized anterior approach. However, the reduction of locked cervical facets can be intricate through anterior approach. We analyzed the safety, efficacy and outcomes at a minimum 1 year, of a novel anterior reduction technique for consecutively treated cervical facet dislocations. MATERIALS AND METHODS: Patients with single level traumatic sub-axial cervical dislocation (n = 39) treated by this modified anterior technique were studied. The technique involved standard Smith-Robinson approach, discectomy beyond PLL, use of inter-laminar distracter to distract while Caspar pins were used as "joysticks" (either flexion-extension or lateral rotation moments are provided), to reduce the sub-luxed facets. Among 51 patients with cervical type C injury treated during the study period, 4 patients who had spontaneous reduction and 8 treated by planned global fusion were excluded. RESULTS: 39 patients of mean age 49.9 years were studied. The levels of injury included (C3-4 = 2, C4-5 = 5, C5-6 = 20, C6-7 = 12). 18 were bi-facetal and 21 were uni-facetal dislocation. One facet was fractured in 17 and both in 5 patients. 30% (n = 13) had a concomitant disc prolapse. The neurological status was as follows: 9 ASIA A, 9 ASIA C, 13 ASIA D and 8 ASIA E. All the patients were successfully reduced by this technique and fixed with anterior locking cervical locking plates. No supplemental posterior surgery was performed. 22 patients with incomplete deficit showed recovery. The mean follow-up was 14.3 months and there was no implant failure except one patient who had partial loss of the reduction. CONCLUSION: Patients with traumatic sub-axial cervical dislocation (AO type C injuries) can be safely and effectively reduced by this technique. Other advantages include minimal blood loss, less risks of infection, shorted fusion zone, good fusion rate and neurological recovery.

A rare cause of recalcitrant coccydynia: benign dermoid cyst masquerading as coccygeal pain.

PURPOSE: Coccydynia is a common entity in orthopedic practice, and various etiologies have been described for it. However, benign dermoid cyst causing coccydynia has not yet been reported. METHODS: A 20-year-old male presented with typical symptoms of coccydynia recalcitrant to conservative treatment for 2 years. Since pain interfered with his daily activities, magnetic resonance imaging was performed which showed a circumscribed precoccygeal cystic lesion. RESULTS: The patient underwent coccygectomy along with cyst excision. Histological examination revealed features of benign dermoid cyst. After surgery, the patient had excellent relief of his symptoms. CONCLUSION: The case report identifies that the treating surgeon should be aware of benign dermoid cyst as one of the treatable but rare causes of intractable coccydynia, and MRI should be performed in patients with persistent coccygeal pain.

Foot pressure transfers are altered in lumbar radiculopathy but reversible after surgery: a prospective, Pedobarography study.

BACKGROUND CONTEXT: Patients with lower lumbar stenosis and disc herniation report disability in standing and ambulation, despite normal neurological examination. The L5 and S1 nerve roots support the entire motor and sensory function of the foot, and their radiculopathy can affect foot loading during standing and walking. This has not been quantified before. PURPOSE: To quantify alterations in static and dynamic foot pressure transfers in patients with lower lumbar nerve root compression, and document any beneficial effects of surgical decompression. STUDY DESIGN: Prospective, case-control study. PATIENT SAMPLE: Cases-Patients with unilateral radiculopathy (L5/S1) with normal neurology (n=50); Controls - Healthy volunteers (n=50). METHODS: The volunteers and patients underwent pedobarographic analysis during standing (static) and walking (dynamic), and fifteen (12 dynamic and three static) parameters were documented. The patient's preoperative values were compared with that of the healthy volunteers. All the 50 patients underwent surgical decompression, and clinical outcome measures (VAS/ODI at 3 months) were documented. Pedobarographic analysis was repeated in the postoperative period (48 hours) and 3-month follow-up and compared with the preoperative scores. RESULTS: In healthy controls, the mean values of all 15 parameters were comparable between the right and the left side (p>.05). When compared to controls, the patients had significantly lower maximum foot loads (p=.01) and average foot loads (p=.05) on the affected side during walking indicating lesser load transmission, in the preoperative period. Within the affected foot, the load transfer was higher on the first metatarsal/ medial arch while significantly less on the lateral metatarsals (p=.04). The percentage load on whole foot and forefoot was significantly less on standing (p=.01). Significant improvements were noted in the post-operative period, especially in the maximum foot surface area (p=.01), maximum and average foot loads, and improved weight transfers on lateral arch and forefoot (p=.02). The load on whole foot increased significantly from 46.1%±5.5% (preoperative) to 48.1%±5.5% (postoperative) and 49.9%±3.3% at follow-up (p=.01). CONCLUSION: This is the first study using Pedobarography to document altered foot pressure patterns during ambulation in patients with disc herniation and stenosis. Decreased load transfer, asymmetrical and unphysiological distribution of pressures on the affected foot were observed during weight bearing, which improved after surgical decompression.

From Modic to Disc Endplate Bone Marrow Complex - The Natural Course and Clinical Implication of Vertebral Endplate Changes.

STUDY DESIGN: Review article. OBJECTIVES: A review of literature on the epidemiology, natural course, pathobiology and clinical implications of vertebral endplate changes. METHODS: A literature search was performed using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the last 10 years were analysed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "Vertebral endplate changes", "Modic changes", "Disc Endplate Bone Marrow complex". RESULTS: The disc, endplate (EP), and bone marrow region of the spine constitute a unified morphological and functional unit, with isolated degeneration of any one structure being uncommon. Disc degeneration causes endplate defects, which result in direct communication and a constant cross-talk between the disc and the vertebral body. This may result in a persistent inflammatory state of the vertebral bone marrow, serving as a major pain generator. This review article focuses on vertebral endplate changes and how the current understanding has progressed from the Modic classification to the Disc Endplate Bone Marrow complex classification. It provides a clear portrayal of the natural course of these alterations and their clinical implications in low back pain. CONCLUSIONS: In light of the heightened interest and current prominence of vertebral endplate changes within the spine community, we must progress beyond the Modic changes to achieve a comprehensive understanding. The DEBM complex classification will play a major part in disc degeneration research and clinical care, representing a considerable advancement in our understanding of the vertebral endplate changes over the classical Modic changes.

Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish Optimizing Management and Minimizing Risk of Osteoporotic Vertebral Fractures - Perspectives of the AO Spine KF Trauma and Infection Group Key Opinion Leaders.

STUDY DESIGN: Literature review with clinical recommendations. OBJECTIVE: To highlight important studies about osteoporotic spinal fractures (OF) that may be integrated into clinical practice based on the assessment of the AO Spine KF Trauma and Infection group key opinion leaders. METHODS: 4 important studies about OF that may affect current clinical practice of spinal surgeons were selected and reviewed with the aim of providing clinical recommendations to streamline the journey of research into clinical practice. Recommendations were graded as strong or conditional following the GRADE methodology. RESULTS: 4 studies were selected. Article 1: a validation of the Osteoporotic Fracture (OF)-score to treat OF fractures. Conditional recommendation to incorporate the OF score in the management of fractures to improve clinical results. Article 2: a randomized multicenter study comparing romosozumab/alendronate vs alendronate to decrease the incidence of new vertebral fractures. Strong recommendation that the group receiving romosozumab/alendronate had a decreased risk of new OF when compared with the alendronate only group only. Article 3: a systematic literature review of spinal orthoses in the management of. Conditional recommendation to prescribe a spinal orthosis to decrease pain and improve quality of life. Article 4: post-traumatic deformity after OF. A conditional recommendation that middle column injury and pre-injury use of steroids may lead to high risk of post-traumatic deformity after OF. CONCLUSIONS: Management of patients with OF is still complex and challenging. This review provides some recommendations that may help surgeons to better manage these patients and improve their clinical practice.

Understanding Decision Making as It Influences Treatment in Thoracolumbar Burst Fractures Without Neurological Deficit: Conceptual Framework and Methodology.

STUDY DESIGN: This paper presents a description of a conceptual framework and methodology that is applicable to the manuscripts that comprise this focus issue. OBJECTIVES: Our goal is to present a conceptual framework which is relied upon to better understand the processes through which surgeons make therapeutic decisions around how to treat thoracolumbar burst fractures (TL) fractures. METHODS: We will describe the methodology used in the AO Spine TL A3/4 Study prospective observational study and how the radiographs collected for this study were utilized to study the relationships between various variables that factor into surgeon decision making. RESULTS: With 22 expert spine trauma surgeons analyzing the acute CT scans of 183 patients with TL fractures we were able to perform pairwise analyses, look at reliability and correlations between responses and develop frequency tables, and regression models to assess the relationships and interactions between variables. We also used machine learning to develop decision trees. CONCLUSIONS: This paper outlines the overall methodological elements that are common to the subsequent papers in this focus issue.

Using Equipoise to Determine the Radiographic Characteristics Leading to Agreement on Best Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficits.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVES: Our goal was to assess radiographic characteristics associated with agreement and disagreement in treatment recommendation in thoracolumbar (TL) burst fractures. METHODS: A panel of 22 AO Spine Knowledge Forum Trauma experts reviewed 183 cases and were asked to: (1) classify the fracture; (2) assess degree of certainty of PLC disruption; (3) assess degree of comminution; and (4) make a treatment recommendation. Equipoise threshold used was 77% (77:23 distribution of uncertainty or 17 vs 5 experts). Two groups were created: consensus vs equipoise. RESULTS: Of the 183 cases reviewed, the experts reached full consensus in only 8 cases (4.4%). Eighty-one cases (44.3%) were included in the agreement group and 102 cases (55.7%) in the equipoise group. A3/A4 fractures were more common in the equipoise group (92.0% vs 83.7%, P < .001). The agreement group had higher degree of certainty of PLC disruption [35.8% (SD 34.2) vs 27.6 (SD 27.3), P < .001] and more common use of the M1 modifier (44.3% vs 38.3%, P < .001). Overall, the degree of comminution was slightly higher in the equipoise group [47.8 (SD 20.5) vs 45.7 (SD 23.4), P < .001]. CONCLUSIONS: The agreement group had a higher degree of certainty of PLC injury and more common use of M1 modifier (more type B fractures). The equipoise group had more A3/A4 type fractures. Future studies are required to identify the role of comminution in decision making as degree of comminution was slightly higher in the equipoise group.

Predictive Algorithm for Surgery Recommendation in Thoracolumbar Burst Fractures Without Neurological Deficits.

STUDY DESIGN: Predictive algorithm via decision tree. OBJECTIVES: Artificial intelligence (AI) remain an emerging field and have not previously been used to guide therapeutic decision making in thoracolumbar burst fractures. Building such models may reduce the variability in treatment recommendations. The goal of this study was to build a mathematical prediction rule based upon radiographic variables to guide treatment decisions. METHODS: Twenty-two surgeons from the AO Knowledge Forum Trauma reviewed 183 cases from the Spine TL A3/A4 prospective study (classification, degree of certainty of posterior ligamentous complex (PLC) injury, use of M1 modifier, degree of comminution, treatment recommendation). Reviewers' regions were classified as Europe, North/South America and Asia. Classification and regression trees were used to create models that would predict the treatment recommendation based upon radiographic variables. We applied the decision tree model which accounts for the possibility of non-normal distributions of data. Cross-validation technique as used to validate the multivariable analyses. RESULTS: The accuracy of the model was excellent at 82.4%. Variables included in the algorithm were certainty of PLC injury (%), degree of comminution (%), the use of M1 modifier and geographical regions. The algorithm showed that if a patient has a certainty of PLC injury over 57.5%, then there is a 97.0% chance of receiving surgery. If certainty of PLC injury was low and comminution was above 37.5%, a patient had 74.2% chance of receiving surgery in Europe and Asia vs 22.7% chance in North/South America. Throughout the algorithm, the use of the M1 modifier increased the probability of receiving surgery by 21.4% on average. CONCLUSION: This study presents a predictive analytic algorithm to guide decision-making in the treatment of thoracolumbar burst fractures without neurological deficits. PLC injury assessment over 57.5% was highly predictive of receiving surgery (97.0%). A high degree of comminution resulted in a higher chance of receiving surgery in Europe or Asia vs North/South America. Future studies could include clinical and other variables to enhance predictive ability or use machine learning for outcomes prediction in thoracolumbar burst fractures.

Interobserver Reliability in the Classification of Thoracolumbar Fractures Using the AO Spine TL Injury Classification System Among 22 Clinical Experts in Spine Trauma Care.

STUDY DESIGN: Reliability study utilizing 183 injury CT scans by 22 spine trauma experts with assessment of radiographic features, classification of injuries and treatment recommendations. OBJECTIVES: To assess the reliability of the AOSpine TL Injury Classification System (TLICS) including the categories within the classification and the M1 modifier. METHODS: Kappa and Intraclass correlation coefficients were produced. Associations of various imaging characteristics (comminution, PLC status) and treatment recommendations were analyzed through regression analysis. Multivariable logistic regression modeling was used for making predictive algorithms. RESULTS: Reliability of the AO Spine TLICS at differentiating A3 and A4 injuries (N = 71) (K = .466; 95% CI .458 - .474; P < .001) demonstrated moderate agreement. Similarly, the average intraclass correlation coefficient (ICC) amongst A3 and A4 injuries was excellent (ICC = .934; 95% CI .919 - .947; P < .001) and the ICC between individual measures was moderate (ICC = .403; 95% CI .351 - .461; P < .001). The overall agreement on the utilization of the M1 modifier amongst A3 and A4 injuries was fair (K = .161; 95% CI .151 - .171; P < .001). The ICC for PLC status in A3 and A4 injuries averaged across all measures was excellent (ICC = .936; 95% CI .922 - .949; P < .001). The M1 modifier suggests respondents are nearly 40% more confident that the PLC is injured amongst all injuries. The M1 modifier was employed at a higher frequency as injuries were classified higher in the classification system. CONCLUSIONS: The reliability of surgeons differentiating between A3 and A4 injuries in the AOSpine TLICS is substantial and the utilization of the M1 modifier occurs more frequently with higher grades in the system.

Expert Opinion, Real-World Classification, and Decision-Making in Thoracolumbar Burst Fractures Without Neurologic Deficits?

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVES: To compare decision-making between an expert panel and real-world spine surgeons in thoracolumbar burst fractures (TLBFs) without neurological deficits and analyze which factors influence surgical decision-making. METHODS: This study is a sub-analysis of a prospective observational study in TL fractures. Twenty two experts were asked to review 183 CT scans and recommend treatment for each fracture. The expert recommendation was based on radiographic review. RESULTS: Overall agreement between the expert panel and real-world surgeons regarding surgery was 63.2%. In 36.8% of cases, the expert panel recommended surgery that was not performed in real-world scenarios. Conversely, in cases where the expert panel recommended non-surgical treatment, only 38.6% received non-surgical treatment, while 61.4% underwent surgery. A separate analysis of A3 and A4 fractures revealed that expert panel recommended surgery for 30% of A3 injuries and 68% of A4 injuries. However, 61% of patients with both A3 and A4 fractures received surgery in the real world. Multivariate analysis demonstrated that a 1% increase in certainty of PLC injury led to a 4% increase in surgery recommendation among the expert panel, while a .2% increase in the likelihood of receiving surgery in the real world. CONCLUSION: Surgical decision-making varied between the expert panel and real-world treating surgeons. Differences appear to be less evident in A3/A4 burst fractures making this specific group of fractures a real challenge independent of the level of expertise.

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

STUDY DESIGN: A prospective study. OBJECTIVE: to evaluate the impact of vertebral body comminution and Posterior Ligamentous Complex (PLC) integrity on the treatment recommendations of thoracolumbar fractures among an expert panel of 22 spine surgeons. METHODS: A review of 183 prospectively collected thoracolumbar burst fracture computed tomography (CT) scans by an expert panel of 22 trauma spine surgeons to assess vertebral body comminution and PLC integrity. This study is a sub-study of a prospective observational study of thoracolumbar burst fractures (Spine TL A3/A4). Each expert was asked to grade the degree of comminution and certainty about the PLC disruption from 0 to 100, with 0 representing the intact vertebral body or intact PLC and 100 representing complete comminution or complete PLC disruption, respectively. RESULTS: ≥45% comminution had a 74% chance of having surgery recommended, while <25% comminution had an 86.3% chance of non-surgical treatment. A comminution from 25 to 45% had a 57% chance of non-surgical management. ≥55% PLC injury certainity had a 97% chance of having surgery, and ≥45-55% PLC injury certainty had a 65%. <20% PLC injury had a 64% chance of having non-operative treatment. A 20 to 45% PLC injury certainity had a 56% chance of non-surgical management. There was fair inter-rater agreement on the degree of comminution (ICC .57 [95% CI 0.52-.63]) and the PLC integrity (ICC .42 [95% CI 0.37-.48]). CONCLUSION: The study concludes that vetebral comminution and PLC integrity are major dterminant in decision making of thoracolumbar fractures without neurological deficit. However, more objective, reliable, and accurate methods of assessment of these variables are warranted.

The AO Spine Thoracolumbar Injury Classification System and Treatment Algorithm in Decision Making for Thoracolumbar Burst Fractures Without Neurologic Deficit.

STUDY DESIGN: Prospective Observational Study. OBJECTIVE: To determine the alignment of the AO Spine Thoracolumbar Injury Classification system and treatment algorithm with contemporary surgical decision making. METHODS: 183 cases of thoracolumbar burst fractures were reviewed by 22 AO Spine Knowledge Forum Trauma experts. These experienced clinicians classified the fracture morphology, integrity of the posterior ligamentous complex and degree of comminution. Management recommendations were collected. RESULTS: There was a statistically significant stepwise increase in rates of operative management with escalating category of injury (P < .001). An excellent correlation existed between recommended expert management and the actual treatment of each injury category: A0/A1/A2 (OR 1.09, 95% CI 0.70-1.69, P = .71), A3/4 (OR 1.62, 95% CI 0.98-2.66, P = .58) and B1/B2/C (1.00, 95% CI 0.87-1.14, P = .99). Thoracolumbar A4 fractures were more likely to be surgically stabilized than A3 fractures (68.2% vs 30.9%, P < .001). A modifier indicating indeterminate ligamentous injury increased the rate of operative management when comparing type B and C injuries to type A3/A4 injuries (OR 39.19, 95% CI 20.84-73.69, P < .01 vs OR 27.72, 95% CI 14.68-52.33, P < .01). CONCLUSIONS: The AO Spine Thoracolumbar Injury Classification system introduces fracture morphology in a rational and hierarchical manner of escalating severity. Thoracolumbar A4 complete burst fractures were more likely to be operatively managed than A3 fractures. Flexion-distraction type B injuries and translational type C injuries were much more likely to have surgery recommended than type A fractures regardless of the M1 modifier. A suspected posterior ligamentous injury increased the likelihood of surgeons favoring surgical stabilization.

"Satellite pedicle screws" - A novel technique of pedicle screw insertion in obese patients undergoing lumbar fusion.

The presence of thick sub-cutaneous fat and bulky paraspinal musculature mandates extensive surgical dissection in obese patients undergoing open Transforaminal lumbar interbody fusion surgery. Securing a 'converging' pedicle screw trajectory becomes difficult by the counterforces of the erector spinae muscles and thick sub-cutaneous fat in obese patients, especially at the L5-S1 level. We describe the use of a limited standard posterior midline exposure and a separate, far lateral 'satellite' incision to insert pedicle screws in an optimal trajectory in obese patients. Through proper pre-operative planning of the axial and sagittal MRI, the appropriate entry site is determined which is executed intra-operatively to insert pedicle screws freehand. Through a single 1.5 cm incision, both L5-S1 screws were inserted. Fourteen obese patients (mean BMI was 30.5 ± 1.1) received 56 satellite pedicle screws for TLIF at L5-S1 level. The mean age was 48.3 ± 9.7 years. The mean blood loss was 244.8 ± 114 ml and the mean operative time was 126.7 ± 82.8 min. In all patients, the screws were inserted as per pre-operative planning without any difficulties. All wounds healed well without wound complications. There were no screw related complications, and in the antero-posterior and lateral radiographs, there were no screw breaches. Satellite free-hand pedicle screws are safe and easily reproducible. They enable limited dissection of the main surgical wound and well-medialised converging pedicle screws in obese patients.

Preoperative pain sensitivity predicts postoperative pain severity and analgesics requirement in lumbar fusion surgery - a prospective observational study.

BACKGROUND CONTENT: The goal of postoperative pain management is to facilitate the patient's return to normal activity and decrease the detrimental effects of acute postsurgical pain. In order to provide more tailored and successful pain treatment, it is necessary to identify individuals who are at a high risk of experiencing severe postoperative pain. The most precise way to assess pain sensitivity is by determining the pressure pain threshold and heat pain threshold by objective methods using a digital algometer and neurotouch respectively. PURPOSE: The primary aim of the study is to assess the preoperative pain threshold and its influence on postoperative pain severity and analgesics requirements in patients undergoing lumbar fusion surgeries. STUDY DESIGN: Prospective, observational study. PATIENT SAMPLE: Sixty patients requiring a single-level lumbar fusion surgery. OUTCOME MEASURES: Postoperative pain intensity and the amount of postoperative analgesics consumption. METHODS: In our patients, preoperative pain sensitivity was assessed by pressure pain threshold measurements with the help of a digital algometer, and heat pain threshold using a neurotouch instrument. In addition, pain sensitivity questionnaires (PSQ) were used in all our patients to determine pain sensitivity. Preoperative psychosocial and functional assessments were performed by Hospital anxiety-depression scores (HADS), and Oswestry disability index (ODI) respectively. Preoperative visual analog scale (VAS) score was determined at three instances of needle prick (phlebotomy, glucometer blood sugar, and intradermal antibiotic test dose) and during the range of movements of the lumbar spine region. Postoperative VAS score and postoperative breakthrough analgesic requirements were recorded in all of these patients from day 0 to day 3. RESULTS: The average age of the patients was 51.11±13.467 years and 70% were females. Females had lower mean algometry values (72.14±7.56) compared to males (77.34±6.33). Patients with higher HADS (p<.0016), higher PSQ (p<.001), higher ODI scores(p<.001), and female gender significantly correlated with a lower algometer average indicating high pain sensitivity. Patients with lower preoperative VAS scores and with higher neurotouch scores showed lower postoperative VAS scores at different time periods. Preoperative VAS scores, algometer average scores, neurotouch scores, and HADS scores were considered as independent variables (predictors) for postoperative VAS at 6 hours period. By the multivariate analysis, factors like preoperative VAS scores, algometer average scores, and HADS scores were statistically significant (p<.05). There was a significant correlation between algometer average scores (p<.001) with the breakthrough analgesics. CONCLUSION: Preoperative assessment of pain sensitivity can predict postoperative analgesic requirements and aid in recovery. Patients with a lower pain threshold should be counseled preoperatively and also receive a better titration of analgesics perioperatively.