Spondylotic traumatic central cord syndrome: a hidden discoligamentous injury?

PURPOSE: To revisit the concept of spondylotic traumatic central cord syndrome (TCCS) by assessing the frequency of discoligamentous injury and to correlate magnetic resonance imaging (MRI) and intraoperative findings. METHODS: A retrospective analysis of twenty-three consecutive patients (mean age: 62.7 ± 14.8 years) with profound spondylotic TCCS after acute cervical hyperextension trauma but without signs of instability on initial CT scans who underwent anterior surgical decompression and fusion was performed. Sensitivity and specificity of MRI in the detection of anterior longitudinal ligament disruption were calculated. The topographic relations between surgically verified segmental instabilities and spinal cord signals on MRI were analyzed. The cervical MRI scans of all patients were evaluated by the radiologist on call at time of admission, re-assessed by a specialized MRI radiologist for the purpose of this study and compared with intraoperative findings. RESULTS: Intraoperative findings revealed 25 cervical spine segments with hyperextension instability in 22 of 23 (95.7%) patients. The radiologist on call correctly assessed segmental hyperextension instability in 15 of 25 segments (sensitivity: 0.60, specificity: 1.00), while the specialized MRI radiologist was correct in 22 segments (sensitivity: 0.88, specificity: 1.00). In 17 of 23 (73.9%) patients, the level of spinal cord signal on MRI matched the level of surgically verified segmental instability. CONCLUSIONS: Our findings challenge the traditional concept of spondylotic TCCS as an incomplete cervical spinal cord injury without discoligamentous injury and emphasize the importance of MRI as well as the radiologist's level of experience for the assessment of segmental instability in these patients. These slides can be retrieved under Electronic Supplementary Material.

Monosegmental anterior column reconstruction using an expandable vertebral body replacement device in combined posterior-anterior stabilization of thoracolumbar burst fractures.

INTRODUCTION: In combined posterior-anterior stabilization of thoracolumbar burst fractures, the expandable vertebral body replacement device (VBRD) is typically placed bisegmentally for anterior column reconstruction (ACR). The aim of this study, however, was to assess feasibility, outcome and potential pitfalls of monosegmental ACR using a VBRD. In addition, clinical and radiological outcome of monosegmental ACR was related to that of bisegmental ACR using the same thoracoscopic technique. METHODS: Thirty-seven consecutive neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2) treated by combined posterior-anterior stabilization were included. Monosegmental ACR was performed in 18 and bisegmental ACR in 19 patients. Fracture type and extent of vertebral body comminution were determined on preoperative CT scans. Monosegmental and bisegmental kyphosis angles were analyzed preoperatively, postoperatively and at final radiological follow-up. Clinical outcome was assessed after a minimum of 2 years (74 ± 45 months; range 24-154; follow-up rate 89.2%) using VAS Spine Score, RMDQ, ODI and WHOQOL-BREF. RESULTS: Monosegmental ACR resulted in a mean monosegmental and bisegmental surgical correction of - 15.6 ± 7.7° and - 14.7 ± 8.1°, respectively. Postoperative monosegmental and bisegmental loss of correction averaged 2.7 ± 2.7° and 5.2 ± 3.7°, respectively. Two surgical pitfalls of monosegmental ACR were identified: VBRD positioning (1) onto the weak cancellous bone (too far cranially to the inferior endplate of the fractured vertebra) and (2) onto a significantly compromised inferior endplate with at least two (even subtle) fracture lines. Ignoring these pitfalls resulted in VBRD subsidence in five cases. When relating the clinical and radiological outcome of monosegmental ACR to that of bisegmental ACR, no significant differences were found, except for frequency of VBRD subsidence (5 vs. 0, P = 0.02) and bisegmental loss of correction (5.2 ± 3.7° vs. 2.6 ± 2.5°, P = 0.022). After exclusion of cases with VBRD subsidence, the latter did not reach significance anymore (4.9 ± 4.0° vs. 2.6 ± 2.5°, P = 0.084). CONCLUSIONS: This study indicates that monosegmental ACR using a VBRD is feasible in thoracolumbar burst fractures if the inferior endplate is intact (incomplete burst fractures) or features only a single simple split fracture line (burst-split fractures). If the two identified pitfalls are avoided, monosegmental ACR may be a viable alternative to bisegmental ACR in selected thoracolumbar burst fractures to spare a motion segment and to reduce the distance for bony fusion.

Treatment and outcome with traumatic lesions of the olecranon and prepatellar bursa: a literature review apropos a retrospective analysis including 552 cases.

BACKGROUND: Traumatic lesions of the olecranon bursa (OB) and prepatellar bursa (PB) are injuries commonly seen in orthopaedic trauma units. These injuries are associated with a high rate of complications. At present, only little is known about the incidence, complication rate, and treatment approaches in patients with acute open bursae. MATERIALS AND METHODS: A total of 552 patients who had been treated for acute traumatic lesions of either the olecranon bursa or the prepatellar bursa, or both at our department were retrospective identified in the years between 2009 and 2014. An analysis of the medical history of these patients was carried out to investigate the incidence of bursa injuries, circumstances, concomitant injuries, complication rate, and treatment approaches. In addition, a systematic literature search on PubMed was conducted. RESULTS: The incidence of traumatic lesions of the OB or PB in trauma patients was 0.2% (198/100,000; 62% OB, 38% PB). Bursectomy was performed in 83.7%. Concomitant injuries were present in 41% of the cases, with no significant influence on the complication rate (P = 0.367). The overall complication rate was 19.7%. Revision surgery was necessary in 4.5% of the patients. No significant differences between OB and PB injuries were noted with regard to the complication rate (P = 0.221). There were also no significant differences in the complication rate between patients who received bursectomy and those with conservative treatment (P = 0.364). Regression analyses showed that prophylactic antibiotic administration significantly reduced the risk of infection (P = 0.04). CONCLUSIONS: Traumatic lesions of the OB and PB are associated with a high risk of complications. Prophylactic antibiotic therapy can potentially reduce the risk of infection and the need for revision surgery.

Treatment of large posttraumatic tibial bone defects using the Ilizarov method: a subjective outcome assessment.

BACKGROUND: The treatment of large posttraumatic tibial bone defects using the Ilizarov method was shown to be successful in several studies. These studies, however, typically focus on the radiological and functional outcome using objective parameters only. The aim of the present study was therefore to assess the objective and subjective outcome of a consecutive series of patients with large posttraumatic tibial bone defects using the Ilizarov method. Additionally, it was our goal to assess the physical and mental stress for the patients and their relatives during the long treatment period and the general health status at final follow-up. METHODS: A consecutive series of 15 patients with posttraumatic tibial bone defects of >30 mm after sustaining open tibial fractures and failure of internal fixation was included. The objective outcome was assessed at final follow-up using Paley's criteria. For the assessment of the subjective outcome, all patients were asked to evaluate their satisfaction with the function of the lower leg, the cosmetic appearance and overall outcome as well. The physical and mental stress of the treatment for the patients and the nearest relative of patients were assessed at the time of frame removal using a custom-made questionnaire. The SF-36 was used to evaluate the general health status at final follow-up. RESULTS: Solid bone union with stable soft tissue coverage and eradication of infection was achieved in all patients despite a high complication rate. The functional outcome at final follow-up was excellent or good in all patients. The patients' satisfaction with the overall outcome and the function of the lower extremity was high as well. The fear of amputation and complications was the major subjective burden for both the patients and their relatives. The long external fixation time is another relevant issue. CONCLUSION: The Ilizarov method is a safe option for the treatment of large posttraumatic tibial bone defects after failure of internal fixation despite the high complication rate. It is essential to comment this to the patients and their relatives prior to the application of the frame increase their compliance with the long and emotionally draining treatment. The Ilizarov method is worth the effort only in patients, who will presumably comply with this treatment option and all of its drawbacks.

Pedicle screw augmentation in posterior constructs of the thoracolumbar spine: How many pedicle screws should be augmented?

BACKGROUNDS: To evaluate the effects of different pedicle screw augmentation strategies on screw loosening and adjacent segment collapse at the proximal end of long-segment instrumentation. METHODS: Eighteen osteoporotic (9 male, 9 female donors; mean age: 74.7 ± 10.9 [SD] years) thoracolumbar multi-segmental motion segments (Th11 - L1) were assigned as follows: control, one-level augmented screws (marginally), and two-level augmented screws (fully augmented) groups (3 × 6). Pedicle screw placement was performed in Th12 and L1. Cyclic loading in flexion started with 100-500 N (4 Hz) and was increased by 5 N every 500 cycles. Standardized lateral fluoroscopy images with 7.5 Nm loading were obtained periodically during loading. The global alignment angle was measured to evaluate the overall alignment and proximal junctional kyphosis. The intra-instrumental angle was used to evaluate screw fixation. FINDINGS: Considering screw fixation as a failure criterion, the failure loads of the control (683 N), and marginally (858 N) and fully augmented (1050 N) constructs were significantly different (ANOVA p = 0.032).Taking the overall specimen alignment as failure criteria, failure loads of the three groups (control 933 ± 271.4 N, marginally 858 N ± 196 N, and full 933 ± 246.3 N were in the same range and did not show any significance (p = 0.825). INTERPRETATION: Global failure loads were comparable among the three groups and unchanged with augmentation because the adjacent segment and not the instrumentation failed first. Augmentation of all screws showed significant improved in screw anchorage.

Bilateral medial medullary syndrome following anterior screw fixation of type 2 odontoid fracture, a case report of two patients.

INTRODUCTION: Medial medullary syndrome (MMS) has not been reported after anterior screw fixation of an odontoid type 2 fracture. CASE PRESENTATION: We report on two cases who suffered from an unstable type 2 odontoid fracture following a skiing and a domestic fall accident. Prior to anterior screw fixation surgery both patients presented without neurologic deficits but postoperatively developed a bilateral MMS, including an incomplete tetraparesis, impaired sensation of position and movement as well as tactile discrimination and paralysis of the tongue muscle with deviation to the paralyzed side. MRI showed a typical heart-shaped ischaemic lesion in the medial medulla bilaterally. The search for aetiologic factors was uneventful in both patients except for severe atherosclerosis. DISCUSSION: Due to the close proximity of the ischaemic area to the surgical site, we here propose the perioperative mechanical manipulation of the upper cervical spine during surgery of patients with atherosclerosis as a new aetiology for MMS.

Cervical Disc and Ligamentous Injury in Hyperextension Trauma: MRI and Intraoperative Correlation.

BACKGROUND AND PURPOSE: To identify and evaluate diagnostic magnetic resonance imaging (MRI) features in patients with suspicion of discoligamentous cervical injury after hyperextension trauma of the cervical spine. METHODS: MR images with a standard protocol (1.5 T, including sagittal T2-weighted images and short tau inversion recovery [STIR]) in 21 patients without any sign of fracture or instability on multidetector computed tomography of the cervical spine were assessed. Among other structures we evaluated the following: prevertebral hematoma, anterior longitudinal ligament (ALL), intervertebral disc, and spinal cord. Presence and the anatomic level of injury were identified and recorded. Results were then compared with intraoperative findings as a reference standard. Simple descriptive statistical analysis, agreement coefficients (given by calculating the percent agreement), and the determination of Gwet's AC1 coefficient were used to analyze our results. RESULTS: The overall percent agreement between STIR and intraoperative findings was 90.9% (AC1 = .881) and for T2 69.7% (AC1 = .498). For the ALL, the overall agreement was 87.9% (AC1 = .808) and for the intervertebral disc 78.8% (AC1 = .673), in which STIR always showed a higher agreement. Prevertebral hematoma was found in 20 of 21 patients with the maximum thickness at the same anatomic level as the intraoperatively proven lesion in 12 of 18 patients (67%). Edema and/or hemorrhage of the spinal cord was shown in 16 of 21 being at the same anatomic level as the intraoperatively confirmed pathology in 16 of 16 patients (100%). CONCLUSIONS: MRI is a reliable tool for the evaluation of discoligamentous injuries in the cervical spine, with ancillary features proven as helpful information.

Blobbing injury patterns.

INTRODUCTION: "Blobbing" is a modern outdoor activity where a participant sits on the end of a partially inflated air bag ("blobber") and is launched into the water when another participant jumps onto the air bag from a platform on the opposite side ("jumper"). This is the first study to evaluate the injury patterns associated with blobbing. PATIENTS AND METHODS: A retrospective data analysis was conducted based on 86 patients who sustained blobbing injuries between January 2011 and December 2016. The date of birth, gender, day of injury, diagnosis, body region of trauma, and treatment were recorded for the patients. Treatment was subclassified into conservative or surgical treatment. The position of the participant was recorded as either a jumper or a blobber. RESULTS: One-third of the patients sustained a spine injury, which was the most common body part injured. The most frequent type of injury was cervical spine distortion. All shoulder (n = 9), elbow (n = 3), hand (n = 2), knee (n = 3), and foot (n = 12) injuries occurred in jumpers, whereas all ear (n = 6) and lung (n = 5) injuries occurred in blobbers. Head (n = 5) and spine (n = 33) injuries were distributed in jumpers and blobbers. Sixty-nine patients were treated with conservative treatment. Three ankle fractures and two spine fractures were treated with immediate surgical treatment. Twelve patients were treated with conservative treatment but were referred for potential surgery at their hospital at home. CONCLUSION: Both jumpers and blobbers were prone to injuries. More severe injuries with the potential for surgical treatment occurred in jumpers, presumably because of bad landings. This analysis of the injury patterns in blobbers might lead to the introduction of protective gear and changes in the behavior of participants in order to reduce the risk of injury.

Fragility fractures requiring special consideration: vertebral fractures.

The treatment of osteoporotic vertebral fractures is complicated because of the comorbid conditions of the elderly patient. Underlying osteoporosis leads to malalignment of the weakened bone and impedes fracture fixation. The treatment of osteoporotic vertebral fractures is widely empirical, because standardized and accepted treatment evidence-based concepts are missing for certain fracture types. As in other osteoporotic fractures in the elderly, the key for good outcome may be a combination of interdisciplinary treatment approaches and adapted surgical procedures. This article gives an overview of the underlying problems and possible treatment strategies for treatment of osteoporotic vertebral fractures in geriatric patients.

Hemorrhage after low-energy pelvic trauma.

BACKGROUND: Severe pelvic hemorrhage after low-energy trauma has been described in some reports of single cases only. However, it might not be as rare and unique as generally expected. The aim of this study was therefore to present a case series of 11 patients with severe pelvic hemorrhage after sustaining low-energy trauma and to discuss relevant considerations for the management of these patients. METHODS: A consecutive series of eleven patients with pelvic hemorrhage and the need for arterial embolization after sustaining low-energy pelvic trauma was identified. A contrast-enhanced computed tomography (CT) scan was performed in all patients, if pelvic hemorrhage was suspected due to a relevant hemoglobin (Hb) drop. After the CT scans showed active arterial bleeding, arterial embolization was immediately performed. RESULTS: All patients sustained low-energy pelvic injuries after simple falls from standing height. The mean initial Hb level was 13.0 g/dL.Contrast-enhanced CT scans were performed after a mean of 14.3 hours after trauma and showed contrast medium extravasations in all patients. The mean Hb level at the time of CT scan was 9.0 g/dL. Embolization was successfully performed in all patients within a mean of 4.5 hours. CONCLUSIONS: Geriatric patients are prone to arterial hemorrhage after low-energy pelvic trauma. They should be admitted as an inpatient for observation with repeated control of the Hb level to diagnose hemorrhage at an early stage. Contrast-enhanced CT scans is the preferred imaging method for the assessment of pelvic hemorrhage, whereas arterial embolization is highly successful in terms of hemostasis.

Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures: A Report of 2 Cases.

In this case report, we present 2 cases of flail chest in geriatric patients after severe blunt chest trauma, which were treated at the University Hospital Innsbruck (Level I Trauma Center and Tyrolean Geriatric Fracture Center) by a multidisciplinary team of physicians from anesthesia, intensive care, trauma surgery, and acute geriatrics. We want to point out the benefit of a multidisciplinary approach in geriatric patients with flail chest.