Assessing Treatment of Floating Lateral Mass (FLM) Fractures of the Subaxial Cervical Spine.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The purpose of the study was to evaluate differences across surgical approaches (anterior, posterior, or combined anterior-posterior) in terms of outcomes following treatment for floating lateral mass (FLM) fractures. Furthermore, we sought to determine whether operative approach to FLM fracture treatment remains superior to nonoperative treatment in terms of clinical outcomes. BACKGROUND DATA: FLM fractures of the subaxial cervical spine involves separation of the lateral mass from the vertebrae via a disruption of both the lamina and pedicle, resulting in a disconnection of the superior and inferior articular processes. This subset of cervical spine fractures is highly unstable, making proper treatment selection of great importance. METHODS: In this single-center, retrospective study, we identified patients meeting the definition of an FLM fracture. Radiological imaging from the date of injury was reviewed to ensure presence this injury pattern. Treatment course was assessed to determine nonoperative versus operative treatment. Operative treatment was divided into patients who underwent anterior, posterior, or combined anterior-posterior spinal fusion. We then reviewed postoperative complications among each of the subgroups. RESULTS: Forty-five patients were determined to have a FLM fracture over a 10-year span. The nonoperative group had n=25, and evidently, there were no patients that crossed over to surgery due to subluxation of the cervical spine after nonoperative treatment. The operative treatment group had n=20, and consisted of 6 anterior, 12 posterior, and 2 combined approaches. Complications appeared in posterior and combined groups. Two hardware failures were noted in the posterior group, along with two postoperative respiratory complications in the combined group. No complications were observed for the anterior group. CONCLUSIONS: None of the nonoperative patients in this study required further operation or management of their injury, indicating nonoperative treatment as a potentially satisfactory management for appropriately selected FLM fractures.

Transpedicular Screw Placement Accuracy Using the O-Arm Versus Freehand Technique at a Single Institution.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The objective of this study was to assess the effectiveness of the O-arm as an intraoperative imaging tool by comparing accuracy of pedicle screw placement to freehand technique. METHODS: The study comprised a total of 1161 screws placed within the cervical (n = 187) thoracic (n = 657), or lumbar (n = 317) spinal level. A pedicle breach was determined by any measurable displacement of the screw outside of the pedicle cortex in any plane on postoperative images. Each pedicle screw was subsequently classified by its placement relative to the targeted pedicle. Statistical analysis was then performed to determine the frequency and type of pedicle screw mispositioning that occurred using the O-arm versus freehand technique. RESULTS: A total of 155 cases (O-arm 84, freehand 71) involved the placement of 454 pedicle screws in the O-arm group and 707 pedicle screws in the freehand group. A pedicle breach occurred in 89 (12.6%) screws in the freehand group and 55 (12.1%) in the O-arm group (P = .811). Spinal level operated upon did not influence pedicle screw accuracy between groups (P > .05). Three screws required revision surgery between the 2 groups (O-arm 1, freehand 2, P > .05). The most frequent breach type was a lateral pedicle breach (O-arm 22/454, 4.8%; freehand 54/707, 7.6%), without a significant difference between groups (P > .05). CONCLUSIONS: The use of the O-arm coupled with navigation does not assure improved transpedicular screw placement accuracy when compared with the freehand technique.

Evaluation of a new spine classification system, does it accurately predict treatment?

STUDY DESIGN: The Thoracolumbar Injury Severity Score (TLISS) was introduced as a novel classifications system. Its aim was to simplify classification of thoracolumbar fractures, grade their severity in an ordinal manner as a guide to management. This study attempted to validate the TLISS as a guide to management. OBJECTIVE: To evaluate the TLISS as a tool for guiding management of thoracolumbar fractures using the outcomes of 97 previously treated spinal fracture. SUMMARY OF BACKGROUND DATA: The TLISS was proposed as a tool for guidance of the management of thoracolumbar fractures to aid the surgeon in choosing management. METHOD: Ninety-seven sequential traumatic thoracolumbar fractures were retrospectively reviewed for their management and outcomes. The presenting clinical information had all personal identifiers removed and the fractures were reevaluated by the treating physician using the TLISS. Eighty-one patients had received management that agreed with the suggested management of the TLISS. Nine patients had a score of 4. Seven patients received management that disagreed with the TLISS. Variables affecting the management that differed from the management suggested by the TLISS were identified in each patient and assessed. RESULT: Of the 97 patients identified, 81 had received management that agreed with the suggested management of the TLISS. Of the 16 remaining patients, 3 patients scored a 3 or less and received an operation, 1 of which, failed conservative management. Four scored a 5 or more and were managed conservatively, none with known failure. Nine patients scored the ambiguous score of 4. Of these, 4 were managed operatively and 5 nonoperatively. CONCLUSIONS: As a management tool, the TLISS seems to consistently suggest treatment consistent with past treatment recommendations. Multilevel contiguous fractures and extension injuries in the ankylosed thoracic spine appear to be the most consistent exceptions to the TLISS guidelines.

Comparative reliability of 3 thoracolumbar fracture classification systems.

STUDY DESIGN: Prospective study of 3 spine surgeons, 3 spine fellows, 3 nonspine orthopedists, and 12 orthopedic residents classifying 97 thoracolumbar fractures using the Denis, Association for Osteosynthesis (AO), and Thoracolumbar Injury Severity Score (TLISS) systems and reclassifying them 3 months later. OBJECTIVE: To compare the reliability of the Denis, AO, and TLISS classification systems and evaluate the skills necessary for their use. SUMMARY OF BACKGROUND DATA: The Denis and AO systems are the traditional methods of classification of thoracolumbar fractures. The purpose of this study was to evaluate a novel classification system, the TLISS and compare its reliability among observers as compared with the Denis and AO classifications. METHOD: Ninety-seven sequential fractures from 1 surgeon's practice at a level 1 trauma center were collected. Twenty-one orthopedic physicians from two area level 1 trauma centers then completed the evaluation of the all fractures. Evaluator experience included staff, spine fellows, and residents. The interobserver and intraobserver reliability were determined. RESULT: In the TLISS, subgroups of evaluators, showed variation in reliability as expected with the highest reliability occurring in the senior resident group and attending spine surgeon group. The lowest reliabilities were in the nonspine attending orthopedists and junior residents. In each group, the neurologic status was consistently the category with the highest interobserver and intraobserver reliability. In the Denis and AO classifications, the highest reliabilities were again in the senior residents and spine attendings. The lowest were again in the nonspine attendings and junior residents. CONCLUSIONS: As a management tool, the TLISS seems to be an acceptably reliable system when compared with the Denis and AO systems. There is a base level of knowledge and familiarity necessary for the application of the system at reliable levels.

Disparities in Access to Musculoskeletal Care: Narrowing the Gap: AOA Critical Issues Symposium.

The current health-care system in the United States has numerous barriers to quality, accessible, and affordable musculoskeletal care for multiple subgroups of our population. These hurdles include complex cultural, educational, and socioeconomic factors. Tertiary referral centers provide a disproportionately large amount of the care for the uninsured and underinsured members of our society. These gaps in access to care for certain subgroups lead to inappropriate emergency room usage, lengthy hospitalizations, increased administrative load, lost productivity, and avoidable complications and/or deaths, which all represent a needless burden on our health-care system. Through advocacy, policy changes, workforce diversification, and practice changes, orthopaedic surgeons have a responsibility to seek solutions to improve access to quality and affordable musculoskeletal care for the communities that they serve.

Face tissue pressures in prone positioning: a comparison of 3 pillows.

STUDY DESIGN: Pilot Study. OBJECTIVE: The objective of this study was to compare face tissue pressures for 3 different prone head positioners in healthy, conscious individuals in the prone position. SUMMARY OF BACKGROUND DATA: The incidence of intraoperatively acquired pressure ulcers has been reported to range from 12% to 66%; healthcare literature lacks information about lesions specific to the face. Risk factors include prolonged surgical times, immobility, inadequate positioning and/or padding, use of warming devices, and skin maceration. Spine procedures are often lengthy, and frequently require patients to be in the prone position. Thus, face pressure lesions have been observed after complex spine procedures. A variety of prone head positioners exist to reduce face tissue pressures encountered during prone procedures. The objective of this study was to compare face tissue pressures for 3 different prone head positioners in healthy, conscious individuals in the prone position. METHODS: Fifteen subjects tested 3 prone face positioners, and face-pillow interface pressures for the forehead and chin were recorded over 15 minutes. The devices included a disposable polyurethane foam prone head positioner (VOSS Medical Product; San Antonio, TX); a face plate and mirror with a disposable foam prone head positioner (ProneView Protective Helmet System, Dupaco Inc; Oceanside, CA); a neoprene "dry flotation" device from ROHO (The ROHO Group; Belleville, IL). RESULTS: At all time points for the forehead and chin, the ProneView positioner and the ROHO neoprene pillow demonstrated significantly lower face-pillow interface pressures than the VOSS polyurethane pillow. CONCLUSIONS: An alternative to the current commercially available prone positioners exists as the ROHO neoprene pillow resulted in significantly lower forehead and chin pressures than the VOSS pillow and lower chin pressures than the ProneView pillow at all time points. A prospective, randomized clinical trial is needed to identify face-pillow interface pressures in anesthetized patients.

The effect of pelvic motion on spinopelvic parameters.

BACKGROUND CONTEXT: To date, many studies have examined how pelvic position affects the spinal curvature and spinopelvic parameters. However, these studies focus on a static relationship, comparing pelvis and spine in a relaxed or baseline position only. Indeed, the spinopelvic connection is dynamic, as subjects can easily be taught to rotate their pelvis anteriorly or posteriorly on the femoral head, all while maintaining an erect posture. Therefore, for a true understanding of pelvic influence on the spinal column, it is necessary to examine spinopelvic parameters in multiple pelvic positions within the same subject. PURPOSE: The objective of this study was to examine the dynamic effect of pelvic motion on the spine and associated radiographic parameters. STUDY DESIGN: This is a single-center, cross-sectional study of 50 healthy, asymptomatic volunteers. PATIENT SAMPLE: Subjects were recruited and screened based on the following criteria: between 18 and 79 years of age; no known spinal, pelvic, or lower extremity pain lasting for >48 hours; no history of spinal, pelvic, or lower extremity dysfunction requiring medical care; no radiographic evidence of spinal or pelvic abnormality, scoliosis deformity, or other associated spinal pathologies; not currently pregnant and with no possibility of being pregnant; and a body mass index of <30. 64. The subjects were screened and 14 were excluded for a total of 50 subjects. OUTCOME MEASURES: The outcome measures included thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic tilt (PT), sacral slope (SS), and pelvic incidence (PI). MATERIALS AND METHODS: This study was funded by a Small Exploratory Research Grant from the Scoliosis Research Society. Each subject was instructed and observed to stand in three different positions: pelvic resting, anterior pelvic rotation, and posterior pelvic rotation. Lateral standing radiographs were taken in each position and each image was examined by an orthopedic spine surgeon who digitally measured the TK, LL, SVA, PT, SS, and PI. The data were then statistically examined to determine the affect of pelvic position on each parameter. RESULTS: Subjects demonstrated a measurable, statistically significant change in each parameter with pelvic rotation. There was a clear pattern of change for LL, PT, and SS with the anterior and posterior pelvic rotations. A change in LL demonstrated a strong correlation with changes in all measured parameters with pelvic rotation. CONCLUSIONS: In asymptomatic subjects, pelvic motion affects the position of the spinal column and resultant spinopelvic parameters. The results of this study demonstrate that one can intentionally change the position of the pelvis and the adjacent spinal column in space. Knowledge of this relationship is important to the understanding of sagittal balance and could influence the treatment of patients with spinal deformity.

Inter/Intraobserver Reliability of T1 Pelvic Angle (TPA), a Novel Radiographic Measure for Global Sagittal Deformity.

STUDY DESIGN: Reliability analysis. OBJECTIVE: To assess intra- and interobserver agreement of the T1 pelvic angle (T1PA), a novel radiographic measure of spinal sagittal alignment. Orthopedic surgeons of various levels of experience measured the T1PA in a series of healthy adult volunteers. The relationship of the TIPA to pelvic position was also assessed. SUMMARY OF BACKGROUND DATA: Recent literature suggests that the T1PA is a more reliable measure of global sagittal alignment than traditional measurements (i.e., sagittal vertical axis). Previous research focuses on postoperative patients with known spinal deformity. No published research exists evaluating the use of T1PA on healthy subjects without spinal deformity. The purpose of this study is: (1) to assess the reliability of measurements of the T1PA, (2) to examine its relationship to pelvic position. METHODS: Seven evaluators of varying orthopedic experience measured the T1PA in 50 healthy adult volunteers. Subjects were radiographed in each of three pelvic positions: resting, maximal anterior pelvic rotation, and maximal posterior pelvic rotation. After a washout period, the measurement was repeated. Using intraclass correlation coefficients, the intra- and inter-rater agreement for the T1PA was measured. The collected data was also used to determine the accuracy of this measurement and its relationship to pelvic position. RESULTS: A very high level of agreement was found in measurements of the T1PA (intraclass correlation coefficients r = 0.98). At each pelvic position, all examiners had excellent intrarater reliability, > 0.85. The inter-rater reliability, compared with a gold standard, consistently measured the T1PA within ±â€Š2°. The data also shows that the T1PA changes with pelvic rotation. CONCLUSION: T1PA is a reproducible and reliable measure of global sagittal alignment regardless of the level of training. The T1PA varies based on pelvic rotation; this variation must be taken into account when assigning an absolute target for correction. LEVEL OF EVIDENCE: 4.

Vacuum-assisted wound closure in postoperative spinal wound infection.

Combined with antibiotic therapy, vacuum-assisted wound closure may help reduce the need for serial irrigation and debridement surgery, contributing to a decrease in overall hospital stay.

Pelvic incidence: a fixed value or can you change it?

BACKGROUND CONTEXT: There has been renewed interest in the pelvic vertebrae by spinal surgeons recently. Those involved in working with patients with adult spinal deformity focus on the position of the fused spine as it relates to the pelvis, and determine success or failure by specific numbers for given pelvic parameters. The pelvic parameters that are commonly measured for these patients are pelvic tilt, sacral slope, and pelvic incidence (PI). Out of the three, PI has always been considered to be the fixed measurement, whereas pelvic tilt and sacral slope have the capacity to change in relation to external forces. The assumption that the PI does not change has not been proven in a healthy, asymptomatic population. PURPOSE: This study aimed to investigate the differences in PI between three pelvic positions used in common functional activities: resting baseline pelvic posture, maximal anterior pelvic rotation, and maximal posterior pelvic rotation. STUDY DESIGN/SETTING: This was a randomized, prospective study of 50 healthy, asymptomatic, individuals who were recruited from the vicinity of our institution. PATIENT SAMPLE: Fifty patients (16 men with a mean age of 26.5±12.1 years; 34 women with a mean age of 27.2±10.8 years) were recruited for this study. Initial screening occurred by telephone. The inclusion criteria consisted of participants being between 18 and 79 years of age, no previous history of spine, pelvic, or lower extremity pain which had lasted longer than 48 hours, or history of any disorder in the spine, pelvis, or lower extremity that had required medical care. Female patients could not be pregnant at the time of participation. OUTCOME MEASURES: Changes in PI were assessed by examining the differences between the values of the PI with each change in pelvic position: resting to maximal anterior pelvic rotation and resting to maximal posterior pelvic rotation. Inter-rater reliability was assessed using Cronbach's alpha. METHODS: This study was funded by a Small Exploratory Grant from the Scoliosis Research Society. All subjects had an initial posterior-anterior and lateral radiograph taken in their resting pelvic position. If no spinal deformity was noted, each subject was instructed to maximally rotate their pelvis anteriorly and an immediate lateral radiograph was taken. The subject was then instructed to maximally rotate their pelvis posteriorly and an immediate lateral radiograph was again taken. Radiographic measurements of PI were independently measured by a board-certified, fellowship trained orthopedic spine surgeon and a board-certified musculoskeletal radiologist after defining and agreeing to the specific manner of measurement. RESULTS: Pelvic incidence values changed in 44 of 50 subjects (88%) when they maximally anteriorly rotated their pelvis from the resting pelvic position. The mean change was 2.9°, with 23 of 50 subjects (46%) changing ≥3°. Pelvic incidence values changed in 40 of 50 subjects (80%) when they maximally posteriorly rotated their pelvis from the resting position. The mean change was 2.82° with 27 of 50 subjects (54%) changing by ≥3°. CONCLUSIONS: This study demonstrated that for a high percentage of the healthy subjects who participated, the PI changed when the subjects varied their pelvic position. This questions the assumption that PI is a fixed parameter and suggests a potential functional motion at the sacroiliac joint. It also supports the idea that intentionally changing one's posture could lead to a change in PI, an idea that could have ramifications in surgical cases.

Results of the Scoliosis Research Society Morbidity and Mortality Database 2009-2012: A Report From the Morbidity and Mortality Committee.

INTRODUCTION: Members of the Scoliosis Research Society are required to annually submit complication data regarding deaths, visual acuity loss, neurological deficit and infection (2012-1st year for this measure) for all deformity operations performed. The purpose of this study is to report the 2012 results and the differences in these complications from the years 2009-2012. METHODS: The SRS M&M database is a self-reported complications registry of deformity operations performed by the members. The data from 2009-2012, inclusive, was tabulated and analyzed. Differences in frequency distribution between years were analyzed with Fisher's exact test. Significance was set at α = 0.05. RESULTS: The total number of cases reported increased from 34,332 in 2009 to 47,755 in 2012. Overall mortality ranged from 0.07% in 2011 to 0.12% in 2009. The neuromuscular scoliosis group had the highest mortality rate (0.44%) in 2010. The combined groups' neurological deficit rate increased from 0.44% in 2009 to 0.79% in 2012. Neurological deficits were significantly lower in 2009 compared to 2012 for idiopathic scoliosis >18 years, other scoliosis, degenerative and isthmic spondylolisthesis and other groups. The groups with the highest neurological deficit rates were dysplastic spondylolisthesis and congenital kyphosis. There were no differences in vision loss rates between years. The overall 2012 infection rate was 1.14% with neuromuscular scoliosis having the highest group rate at 2.97%. CONCLUSION: Neuromuscular scoliosis has the highest complication rates of mortality and infection. The neurological deficit rates of all groups combined have slightly increased from 2009 to 2012 with the highest rates consistently being in the dysplastic spondylolisthesis and congenital kyphosis groups. This could be due to a number of factors, including more rigorous reporting.

Teachability and reliability of a new classification system for lower cervical spinal injuries.

STUDY DESIGN: Reliability and validation study. OBJECTIVE: The objective of this study is to evaluate a new lower cervical spine injury classification system and assess its reliability, teachability, and clinical applications. SUMMARY OF BACKGROUND DATA: The recently proposed Cervical Spine Injury Severity Score (CSISS) morphologically describes lower cervical spine injuries and grades them on a score of 1 to 20 depending on the integrity of the 4 columns that make up the cervical spine. Early data suggests that this classification system is both reliable and reproducible. Reliability data from additional institutions and data exploring teachability of this classification system is not available. METHODS: Fifteen subjects (12 residents and 3 attendings trained in the management of spinal trauma) reviewed radiographs and CT scans of 50 patients and scored them according to the CSISS. Six residents scored the patients 1 month before an instructional lecture given by the senior author and then again immediately following the lecture to assess teachability of the new classification system. All subjects then reviewed the films a final time 1 month later to assess both intraobserver and interobserver reliability. The patients' scores were also analyzed in conjunction with their clinical treatment. RESULTS: Interobserver reliability overall was excellent (0.975) with junior residents performing similarly to those with more extensive training. Intraobserver reliability was also excellent overall (0.983). Teachability scores improved in the ability to score all 4 columns. Furthermore, this classification system was a fair overall predictor of surgical candidates as a score of 7 predicted 19 out of 26 surgical patients (76% sensitivity, 100% specificity). CONCLUSION: The CSISS is a useful new adjunct in the treatment and classification of lower cervical spine injuries. The system is reliable, reproducible, and teachable. It is clinically useful for all levels of orthopedic training and experience.

Face tissue pressure in prone positioning: a comparison of three face pillows while in the prone position for spinal surgery.

STUDY DESIGN: This is a prospective, randomized study. OBJECTIVE: The purpose was to compare the tissue-pillow interface pressures at the forehead and chin in patients positioned in the prone fashion for spinal surgery on each of 3 facial positioners. SUMMARY OF BACKGROUND DATA: Facial pressure ulcers have been infrequently observed after spinal surgery requiring prone positioning. This requires the use of a specially designed head positioner to maintain spinal alignment and to allow space for the endotracheal tube. METHODS: We enrolled 66 consecutive elective thoracic and/or lumbar surgery patients from 18 to 65 years of age. Patients were randomized on entry into the study to 1 of 3 positioners. Facial tissue pressures were measured at the patient's forehead and chin at times 0, 5, 15, and 60 minutes of positioning. The integrity of the patient's skin was recorded and classified at the end of surgery. RESULTS: The pressures measured for the Dupaco positioner were lower at all time points at both the forehead and the chin in comparison with the other 2 positioners (P < 0.05). The ROHO and the OSI positioners created similar chin pressures at all time points (P > 0.05). The pressures at the forehead for the ROHO positioner were significantly less than those for the OSI positioner at all time points (P < 0.05). Ten patients on the OSI positioner had pressure ulcers at the end of the procedure. CONCLUSION: The Dupaco ProneView Protective Helmet System is superior to both the OSI and the ROHO positioners in decreasing forehead and chin tissue interface pressures during prone position surgery.

The role of debridement and antibiotics in gunshot wounds to the spine.

BACKGROUND: The number of spinal cord injuries due to gunshot wounds continues to rise each year, and they currently rank third behind motor vehicle collisions and falls. Spine and wound infections pose difficult problems for transgastrointestinal gunshot wounds to the spine. METHODS: A retrospective review of 114 patients with low-velocity gunshot wounds to the spine was performed. Attention was paid to associated gastrointestinal (GI) tract injuries, antibiotic coverage, surgical intervention, and the development of spine and wound infections. RESULTS: Of 114 patients with gunshot wounds to the spine, 27 (23.7%) sustained a concomitant GI tract injury and 87 (76.3%) did not. Four spine infections (4/114, 3.5%) and 23 wound infections (23/114, 20.2%) developed in our patient population. Spine infection (chi = 13.36, p < 0.001) and wound infection (chi = 12.94, p < 0.001) rates were significantly higher in transgastrointestinal gunshot wounds to the spine. Surgical treatment of the spine in patients with transgastrointestinal gunshot wounds showed a significantly higher rate of spinal infection than did nonsurgical treatment of the spine (p = 0.013, Cramer's V = 0.61). No significant difference in spine infection rate was seen with adequate versus inadequate antibiotic coverage in the trans- gastrointestinal subset (p = 1.00), or in the development of wound infections with spine surgery (p = 0.628) or varying antibiotic coverage (p = 1.00). CONCLUSIONS: There is a significantly higher rate of spine and wound infections with trans-gastrointestinal gunshot wounds to the spine. These injuries, particularly those that involve the colon, put patients at risk for the development of spine infections after spinal surgery. Randomized controlled trials are necessary for the development of a specific protocol for intravenous antibiotic therapy in the setting of transgastrointestinal gunshot wounds to the spine.

Cervical degenerative cyst located within the body of C2: a case report and review of the literature.

STUDY DESIGN: A case report and review of the literature are presented. OBJECTIVES: To describe the clinical course and treatment of a patient with an unusual intraosseous degenerative cyst within the body of the axis, as well as review the literature regarding these lesions. SUMMARY OF BACKGROUND DATA: Intraosseous degenerative cysts of the cervical spine are extremely rare. To our knowledge, only 4 prior case studies have described these lesions, 2 of which were seen in the body of C2. METHODS: A case report of a 58-year-old patient with neck pain and an intraosseous cyst within the axis is presented with a review of the pertinent literature. RESULTS: History, examination, radiographic evaluation, and histology revealed this lesion to be an intraosseous degenerative cyst within the body of C2. The patient was treated with anterior surgical biopsy/curettage and posterior stabilization with structural graft enhancement. CONCLUSION: Although rare, intraosseous cervical degenerative cysts should be present in any differential diagnosis of cystic lesions seen in the cervical spine.