AP pelvis radiograph is insufficient for diagnosis of U-type sacral fractures.

PURPOSE: We investigated the sensitivity of a screening test for pelvic ring disruption, the AP pelvis radiograph, for clinically serious U-type sacral fractures which merit consultation with an orthopedic trauma specialist and may require transfer to a higher level of care. METHODS: Retrospective clinical cohort of 63 consecutive patients presenting with U-type sacral fractures at one level 1 trauma referral center from January 2006 through December 2019. The sensitivity of the first AP pelvis radiograph obtained on admission, interpreted without reference to antecedent or concomitant pelvis computed tomography (CT) by a radiologist and a panel of three blinded orthopedic traumatologists, was determined against a reference diagnosis made from review of all pelvis radiographs, CT images, operative reports, and clinical documentation. RESULTS: Sensitivity of AP pelvis radiograph for U-type sacral fractures was 2% as interpreted by a radiologist and mean 12% (range 5-27%) as interpreted by orthopedic traumatologists with poor inter-rater agreement (Fleiss' κ = 0.11). 94% of sacra were at obscured by radiographic artifact. CONCLUSION: The sensitivity of an AP pelvis radiograph is poor for U-type sacral fractures, whether interpreted by radiologists or orthopedic traumatologists. Pelvis CT should be considered as a screening test to rule out sacral fracture when the patient reports posterior pelvic pain, even if plain radiography demonstrates no injury or a minimally displaced pelvic ring disruption. LEVEL OF EVIDENCE: Diagnostic level III.

Enhanced perioperative care and decreased cost and length of stay after elective major spinal surgery.

OBJECTIVEThe purpose of this study was to compare total cost and length of stay (LOS) between spine surgery patients enrolled in an enhanced perioperative care (EPOC) pathway and patients receiving traditional perioperative care (TRDC).METHODSAll spine surgery candidates were screened for inclusion in the EPOC pathway. This cohort was compared to a retrospective cohort of patients who received TRDC and a concurrent group of patients who met inclusion criteria but did not receive the EPOC (no pathway care [NOPC] group). Direct and indirect costs as well as hospital and intensive care LOSs were analyzed between the 3 groups.RESULTSTotal costs after pathway implementation decreased by $19,344 in EPOC patients compared to a historical cohort of patients who received TRDC and $5889 in a concurrent cohort of patients who did not receive EPOC (NOPC group). Hospital and intensive care LOS were significantly lower in EPOC patients compared to TRDC and NOPC patients.CONCLUSIONSThe implementation of a multimodal EPOC pathway decreased LOS and cost in major elective spine surgeries.

Cervical facet dislocations in the adolescent population: a report of 21 cases at a Level 1 trauma center from 2004 to 2014.

PURPOSE: The purpose of this study was to present a series of adolescent patients with cervical facet dislocations to identify the mechanism of injury, severity of neurological injury and rate of neurological recovery. METHODS: Between 2004 and 2014, a retrospective review at a level I trauma center identified patients with unilateral or bilateral dislocated facet(s). Demographic data, initial neurological exams, surgical data, radiographic findings, and follow-up records were reviewed. RESULTS: Of the 21 adolescent facet dislocations, 7 were unilateral and 14 bilateral. Mean age was 14.9 years; (range 12-17). Male:female ratio was 15:6. All patients presented as a result of a high-energy injury. C6-7 was the most common level of dislocation. 1 of 18 (5.5%) patients had a cervical disc herniation on MRI. Nine (43%) patients had an associated facet fracture (8 unilateral, 1 bilateral). None of the 12 patients who presented as a complete spinal cord injury (SCI) (AISA A) had any neurological recovery. Only one of the three patients who presented as an incomplete SCI (ASIA B, C, D) had an ASIA grade improvement at final follow-up. Six patients who presented were neurologically intact (ASIA E). CONCLUSION: Over half of children with this injury in our study had a complete SCI with no recovery. We believe that the adolescent spine is more resilient to injury, thus requiring a high-energy injury to cause a dislocation, but resulting in a high rate of SCI with a low rate of neurological recovery, and a low rate of cervical disc herniation.

Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naïve spinal surgeons.

PURPOSE: The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably. METHODS: A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ). RESULTS: The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility. CONCLUSION: In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.

Contribution of the patient microbiome to surgical site infection and antibiotic prophylaxis failure in spine surgery.

Despite modern antiseptic techniques, surgical site infection (SSI) remains a leading complication of surgery. However, the origins of SSI and the high rates of antimicrobial resistance observed in these infections are poorly understood. Using instrumented spine surgery as a model of clean (class I) skin incision, we prospectively sampled preoperative microbiomes and postoperative SSI isolates in a cohort of 204 patients. Combining multiple forms of genomic analysis, we correlated the identity, anatomic distribution, and antimicrobial resistance profiles of SSI pathogens with those of preoperative strains obtained from the patient skin microbiome. We found that 86% of SSIs, comprising a broad range of bacterial species, originated endogenously from preoperative strains, with no evidence of common source infection among a superset of 1610 patients. Most SSI isolates (59%) were resistant to the prophylactic antibiotic administered during surgery, and their resistance phenotypes correlated with the patient's preoperative resistome (P = 0.0002). These findings indicate the need for SSI prevention strategies tailored to the preoperative microbiome and resistome present in individual patients.

AO spine injury classification system: a revision proposal for the thoracic and lumbar spine.

PURPOSE: The AO Spine Classification Group was established to propose a revised AO spine injury classification system. This paper provides details on the rationale, methodology, and results of the initial stage of the revision process for injuries of the thoracic and lumbar (TL) spine. METHODS: In a structured, iterative process involving five experienced spine trauma surgeons from various parts of the world, consecutive cases with TL injuries were classified independently by members of the classification group, and analyzed for classification reliability using the Kappa coefficient (κ) and for accuracy using latent class analysis. The reasons for disagreements were examined systematically during review meetings. In four successive sessions, the system was revised until consensus and sufficient reproducibility were achieved. RESULTS: The TL spine injury system is based on three main injury categories adapted from the original Magerl AO concept: A (compression), B (tension band), and C (displacement) type injuries. Type-A injuries include four subtypes (wedge-impaction/split-pincer/incomplete burst/complete burst); B-type injuries are divided between purely osseous and osseo-ligamentous disruptions; and C-type injuries are further categorized into three subtypes (hyperextension/translation/separation). There is no subgroup division. The reliability of injury types (A, B, C) was good (κ = 0.77). The surgeons' pairwise Kappa ranged from 0.69 to 0.90. Kappa coefficients κ for reliability of injury subtypes ranged from 0.26 to 0.78. CONCLUSIONS: The proposed TL spine injury system is based on clinically relevant parameters. Final evaluation data showed reasonable reliability and accuracy. Further validation of the proposed revised AO Classification requires follow-up evaluation sessions and documentation by more surgeons from different countries and backgrounds and is subject to modification based on clinical parameters during subsequent phases.

Thoracic costotransversectomy characteristics and 90-day complications vary based on underlying diagnosis.

OBJECTIVE: Thoracic costotransversectomies are among the most invasive spinal procedures performed and are associated with unanticipated medical and surgical complications. Few studies have specifically assessed medical and surgical complications after a thoracic corpectomy via a costotransversectomy approach (TCT) or compared complications between different diagnoses. The purpose of this study was to describe the differences in operative characteristics and rates of 90-day surgical and medical complications in patients undergoing TCTs based on underlying diagnosis. METHODS: A retrospective chart review of 123 consecutive patients who underwent TCTs at a single academic referral center over a 10-year period was conducted. Surgical indication, corpectomy levels, intraoperative dural tears, pleural injuries, neurological injuries, 90-day mortality, 90-day reoperations, and hospital-based medical complications were evaluated. RESULTS: One hundred twenty-three patients underwent a TCT, including 35 for infection, 42 for malignancy, 23 for trauma, and 23 for deformity. Fifty-nine patients (48.0%) had at least one medical or 90-day operative complication, with 22 patients (17.9%) having two or more complications. Patients with a diagnosis of infection were more likely to undergo two-level corpectomies (80% vs 26.1%, p < 0.0005). Patients with a diagnosis of malignancy had significantly higher 90-day mortality (19.0% vs 4.9%, p = 0.022) and were more likely to undergo three-level corpectomies (9.5% vs 3.7%, p = 0.002) and upper thoracic (T1-4) corpectomies (37.9% vs 12.4%, p = 0.001), and sustain a pleural injury (14.3% vs 2.5%, p = 0.019). Ninety-day reoperation rates (p = 0.970), postoperative ventilator days (p = 0.224), intensive care unit stays (p = 0.350), hospital lengths of stay (p = 0.094), neurological injuries (p = 0.338), and dural tears (p = 0.794) did not significantly vary between the different groups. CONCLUSIONS: Nearly half of the patients undergoing a TCT will experience an unanticipated short-term complication related to the procedure. Short-term complications may vary with the underlying patient diagnosis.

Primary internal fixation of unilateral C1 lateral mass sagittal split fractures: a series of 3 cases.

STUDY DESIGN: Retrospective case review of adult patients who sustained C1 lateral mass sagittal split fractures treated with primary internal fixation. OBJECTIVE: To present the outcomes of patients treated with primary C1 open reduction and internal fixation of this previously described injury. SUMMARY OF BACKGROUND DATA: The majority of C1 fractures can be effectively treated nonoperatively with external immobilization unless there is an injury to the transverse atlantal ligament. We have previously described an uncommon fracture variant involving a unilateral sagittal split of the C1 lateral mass with high propensity for late deformity and pain, despite lack of compromise to the transverse atlantal ligament. METHODS: A retrospective review of all patients with C1 fractures between September 2002 and October 2008 identified 3 consecutive patients from a level I trauma center (Harborview Medical Center, Seattle, WA) with this unique C1 lateral mass fracture treated with primary internal fixation without fusion. Patients' charts and radiographs were reviewed. RESULTS: One patient died within 2 weeks of injury owing to associated injuries. The 2 survivors had follow-up averaging 14 months. Both went on to stable healing with satisfactory alignment. Rotational range of motion averaged an arc of 120 degree at final follow-up. No patient went on to develop the previously described "cock-robin" deformity from subluxation of the lateral mass with settling of the occiput onto the C2 lateral mass. CONCLUSIONS: Patients with a unilateral sagittal split of the C1 lateral mass can be successfully managed with primary open reduction and internal fixation with a transversely oriented construct using C1 lateral mass screws. Internal fixation of the atlas without fusion prevents progressive, painful deformity and the need for complex occipitocervical reconstruction procedures that have been reported with nonoperative management of these injuries.

"Floating Cervical Spine Injuries": Craniocervical Dissociation with Associated, Noncontiguous, Unstable Cervical or Cervicothoracic Spine Fracture.

BACKGROUND: Advances in prehospital life support of patients who have sustained high-energy trauma have resulted in an increase in the number of patients with craniocervical dissociations (CCDs) surviving. With better imaging and more severely injured patients surviving, we are now seeing other associated injuries. CCDs in association with unstable, noncontiguous, subaxial spine injuries have not been described. The objective of this study was to (1) describe this injury pattern and its characteristics, including the mechanism of injury, injury levels, and neurological deficits, and (2) understand prognosis and outcome. METHODS: After institutional review board approval, a retrospective study of patients who sustained CCD in association with an unstable, circumferential, subaxial, or cervicothroacic spine injury (C3-T2) between January 1, 2003, and August 31, 2018, was done. Review of imaging was performed to identify spine injury localization and type. Demographic data, mechanism of injury, neurological status, type of treatment, and patient outcomes were obtained from the electronic medical records. RESULTS: One hundred seventeen patients with CCD were identified, of which 105 had full spine radiographs. Thirteen (8 male and 5 female) had an associated, noncontiguous, unstable cervical, or cervicothoracic injury. Mean age was 45.4 ± 19 years. No exam could be obtained in 6; in the other 7, 1 was American Spinal Injury Association (ASIA) E, 1 ASIA D, and 5 ASIA A. Operative management of both injuries was planned for all 13 patients; however, 2 died before surgery. At discharge, there were 9 survivors with mean follow up of 2 years; 4 patients were independent (3 ASIA D, 1 ASIA E), and 5 were dependent (1 ASIA C, 4 ASIA A). CONCLUSIONS: Approximately 12% of patients with CCD have a floating cervical spine injury. Floating cervical spine injuries have an unfavorable prognosis with 69% surviving to hospital discharge but only 31% functioning independently (ASIA D or E). LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Floating cervical spine injuries need to be recognized to optimize prognosis, yet even in the best of circumstances, prognosis is guarded.

Incidence and degrees of neurologic decline following thoracic costotransversectomy.

BACKGROUND CONTEXT: Thoracic costotransversectomies (TCT) are amongst the most invasive spine procedures performed. Of greatest concern to the patient and surgeon is the risk of iatrogenic neurologic injury associated with these procedures. Most available studies limit their assessment of neurologic function to nonspecific scales such as the broader ASIA scoring system of A to E and have not comprehensively described the rates of iatrogenic injury following these procedures by looking more precisely with ASIA motor scoring (0-100) which allows for more in-depth analysis. PURPOSE: The purpose of this study is to investigate the rates and degree of iatrogenic neurologic decline following TCT and subsequent rates and degree of motor recovery. STUDY DESIGN/SETTING: Retrospective medical record review at a single institution. PATIENT SAMPLE: Around 116 consecutive patients undergoing TCT operations. OUTCOME MEASURES: Neurological changes from preprocedure to final follow-up assessed by lower extremity motor score. METHODS: A retrospective chart review of patients undergoing TCT between May 2008 and April 2018 was carried out. Clinical, surgical, and intraoperative neuromonitoring data were collected. Patients who demonstrated an initial postoperative decline in lower extremity motor scores (LEMS) were followed through their final follow up to assess recovery. RESULTS: Around 116 patients underwent TCT between T2 and T12 between May 2008 and April 2018. Seven (6.0%) patients demonstrated an immediate postoperative decline as defined by a drop of more than 4 points (mean 15.1; range 5-50) in motor score. All patients who demonstrated an initial postoperative motor score decline returned to within 4 LEMS points of their preoperative LEMS by final follow up. IOMN changes were noted only in half of all monitored patients who were noted to have a decline. CONCLUSIONS: In our series, 6.0% of patients undergoing TCT experienced an initial decline in motor score with 94.0% demonstrating an unchanged or improved examination compared to preoperative exam. In our series, all patients who exhibited a decline recovered to within 4 points of the preoperative motor score within the first year postoperatively.

Advanced compressive extension injuries of the subaxial cervical spine: do we really understand the nuances of this injury?

BACKGROUND CONTEXT: The Allen and Ferguson classification of cervical spine injuries is widely used. They described compressive Extension (CE) injuries as having five progressive stages. Stage 4(CE4) and 5(CE5) have been described as having a posterior vertebral arch fracture involving two motion segments accompanied by displacement (dislocation) of the vertebral body at a single level. However, in their original work, CE4 was described only as a hypothetical stage, while CE5 was found in only three patients. Beyond this, little is understood about these injuries. PURPOSE: To identify characteristics of compression extension injuries with vertebral body displacement (CE4 and CE5) from a series of surgically treated subaxial cervical spine fractures. A secondary aim was to identify specific characteristics that may guide treatment or affect prognosis. DESIGN: Retrospective case series. PATIENT SAMPLE: Twenty-four patients who underwent surgical stabilization of CE4 and CE5 cervical spine fracture-dislocations in non-ankylosed spines over a 14-year period. OUTCOME MEASURES: Radiographic categorization of CE injury type, treatment rendered, postoperative spinal alignment, presence of nonunion, loss of fixation, hardware-related and neurologic complications. METHODS: After IRB approval, patients with CE injuries were identified through billing data and radiology records at a level I trauma center between January 2005 and September 2018. Demographic data, ISS, ASA, motor score, and complications during the hospitalization were collected from the patient's EMR. CT scans were reviewed to assess fracture pattern, level, and location of the vertebral arch fracture, vertebral body displacement, spinal canal diameter and method of surgical stabilization. Injuries were classified according to the classification of Allen and Ferguson, and the AO subaxial cervical spine classification. RESULTS: Of 221 patients identified with CE mechanism, 24 had CE4 or CE5 injuries. High-energy mechanism occurred in 92% of the patients, with motor vehicle accidents being the most common. The average ASIA motor score was 80 preoperatively and 84 at average 398 days follow-up. All CE4 and CE5 injuries occurred at C6-C7 or C7-T1. Average anterolisthesis was 6.26 mm (SD ± 2.3 mm) for CE4 and 16.8 mm (SD ± 1.8 mm) for CE5. Average spinal canal diameter at the level of dislocation was 20 mm (SD ± 0.4 mm) for CE4 and 30.5 mm (range 29.6 - 31.4 mm) for CE5. The surgical approach was anterior in 5 patients, posterior in 12 patients, and combined in 7 patients. Four patients had single-evel fixation, all of whom had CE4 injuries, and 20 patients had fixation across two or more levels. Thirty percent of patients had complications, none of which included postoperative spinal malalignment, nonunion or hardware-related complications, or worsening of neurologic exam. Three deaths occurred in the postoperative hospitalization period (7 to 15 days). CONCLUSION: CE4 and CE5 injuries represented 10% and 1% of all CE injuries in our series respectively occurring only at the C6-C7 and C7-T1 levels. Though by original description these are two-level injuries, in patients with milder posterior element injury, single level stabilization was used successfully. We have therefore proposed designating CE4 into less severe CE4a and more severe CE4b injuries. Because this fracture pattern typically results in widening of the spinal canal as the anterior displacement of the vertebral body occurs independent of the fractured posterior elements, spinal cord injuries are neither as severe nor as common as in fracture-dislocation from other mechanisms.

The mandible-C2 angle: a new radiographic assessment of occipitocervical alignment.

BACKGROUND CONTEXT: Occipitocervical fusion is a rare and often challenging surgical procedure. Significant morbidity can result if care is not taken to achieve physiologic alignment. This is especially true for patients needing occipitocervical fusion in the setting of trauma where preoperative alignment is unknown. PURPOSE: To assess the radiographic angles normally subtended between the C2 body and the mandible ramus, in a series of patients with neutral physiologic alignment and no pathology, and to assess its validity as a possible intraoperative radiographic tool to determine a neutral craniocervical alignment. DESIGN: Validation and reliability study of radiographic parameters. PATIENT SAMPLE: Hundred lateral, neutral, cervical radiographs from patients with "normal" radiographic findings. OUTCOME MEASURES: Radiographic parameters of occipital-cervical alignment with assessment of reliability and correlation in data. METHODS: One hundred neutral lateral cervical spine radiographs in the upright position of patients with no complaints or known pathology were obtained from two medical clinics between December of 2014 and January of 2017. Three physicians, at different levels of spine surgery training, took measurements of radiographic parameters. The new technique used four different angles measured between the C2-body/dens complex and the mandibular ramus (anterior/posterior C2 body and anterior/posterior mandible lines angles), and compared these with the Occipito-C2 angle, which is a validated assessment of occipitocervical alignment. Statistical analysis was performed to assess correlation in data and measure reproducibility. RESULTS: Between the three reviewers, the mean±standard deviation were 18.0°±6.5° for Occipito-C2 angle (O-C2A), -4.2°±5.4° for anterior C2-body/anterior mandible line angle (AB/AM), -4.2°±5.9° for anterior C2-body/posterior mandible line angle (AB/PM), 5.1°±5.8° for posterior C2 body/anterior mandible line angle (PB/AM) and 5.6°±6.2° for posterior C2 body/ posterior mandible line angle (PB/PM). Overall the measurements obtained were correlative with an appropriate range for the standard deviation. Mean intraclass correlation coefficient were 0.889 for O-C2A, 0.795 for AB/AM, 0.859 for AB/PM, 0.876 for PB/AM, and 0.750 for PB/PM, showing high interobserver reliability for all the radiographic measures. Across the five techniques, 87%-92% of measurements fell within 10° of the median, 76%-83% fell within 7.5°, and 55%-66% within 5°. CONCLUSIONS: The mandible-C2 angle offers a reproducible alternative to the validated O-C2A technique for determining appropriate intraoperative occipitocervical alignment, which may be especially useful when preoperative radiographic alignment is unknown, such as occurs with trauma patients, with the goal of decreasing alignment-related complications in the setting of occipitocervical stabilization.

Hospital and Surgeon Variation in Patient-reported Functional Outcomes After Lumbar Spine Fusion: A Statewide Evaluation.

STUDY DESIGN: Statewide retrospective cohort study using prospectively collected data from the Spine Care and Outcomes Assessment Program, capturing ∼75% of the state's spine fusion procedures. OBJECTIVE: The aim of this study was to estimate the variation in patient-reported outcomes (PROs) 1 year after elective lumbar fusion surgery across surgeons and hospitals; and to discuss the potential impact of guiding patient selection using a PRO prediction tool. SUMMARY OF BACKGROUND DATA: Despite an increasing interest in incorporating PROs as part of the move toward value-based payment and to improve quality, limited evidence exists on how PROs vary across hospitals and surgeons, a key aspect of using these metrics for quality profiling. METHODS: We examined patient-reported functional improvement (≥15-point reduction in the Oswestry Disability Index [ODI]) and minimal disability (reaching ≤22 on the ODI) 1 year after surgery in 17 hospitals and 58 surgeons between 2012 and 2017. Outcomes were risk-adjusted for patient characteristics with multiple logistic regressions and reliability-adjusted using hierarchical models. RESULTS: Of the 737 patients who underwent lumbar fusion (mean [SD] age, 63 [12] years; 60% female; 84% had stenosis; 70% had spondylolisthesis), 58.7% achieved functional improvement and 42.5% reached minimal disability status at 1 year. After adjusting for patient factors, there was little variation between hospitals and surgeons (maximum interclass correlation was 3.5%), and this variation became statistically insignificant after further reliability adjustment. Avoiding operation on patients with <50% chance of functional improvement may reduce current surgical volume by 63%. CONCLUSION: Variations in PROs across hospitals and surgeons were mainly driven by differences in patient populations undergoing lumbar fusion, suggesting that PROs may not be useful indicators of hospital or surgeon quality. Careful patient selection using validated prediction tools may decrease differences in outcomes across hospitals and providers and improve overall quality, but would significantly reduce surgical volumes. LEVEL OF EVIDENCE: 3.

Description and Reliability of the AOSpine Sacral Classification System.

BACKGROUND: Several classification systems exist for sacral fractures; however, these systems are primarily descriptive, are not uniformly used, have not been validated, and have not been associated with a treatment algorithm or prognosis. The goal of the present study was to demonstrate the reliability of the AOSpine Sacral Classification System among a group of international spine and trauma surgeons. METHODS: A total of 38 sacral fractures were reviewed independently by 18 surgeons selected from an expert panel of AOSpine and AOTrauma members. Each case was graded by each surgeon on 2 separate occasions, 4 weeks apart. Intrarater reproducibility and interrater agreement were analyzed with use of the kappa statistic (κ) for fracture severity (i.e., A, B, and C) and fracture subtype (e.g., A1, A2, and A3). RESULTS: Seventeen reviewers were included in the final analysis, and a total of 1,292 assessments were performed (646 assessments performed twice). Overall intrarater reproducibility was excellent (κ = 0.83) for fracture severity and substantial (κ = 0.71) for all fracture subtypes. When comparing fracture severity, overall interrater agreement was substantial (κ = 0.75), with the highest agreement for type-A fractures (κ = 0.95) and the lowest for type-C fractures (κ = 0.70). Overall interrater agreement was moderate (κ = 0.58) when comparing fracture subtype, with the highest agreement seen for A2 subtypes (κ = 0.81) and the lowest for A1 subtypes (κ = 0.20). CONCLUSIONS: To our knowledge, the present study is the first to describe the reliability of the AOSpine Sacral Classification System among a worldwide group of expert spine and trauma surgeons, with substantial to excellent intrarater reproducibility and moderate to substantial interrater agreement for the majority of fracture subtypes. These results suggest that this classification system can be reliably applied to sacral injuries, providing an important step toward standardization of treatment.

Traumatic Craniocervical Dissociation in Patients with Congenital Assimilation of the Atlas to the Occiput.

Traumatic atlantooccipital dissociation (AOD) is a severe and usually fatal injury. Patients with assimilation of the atlas to the skull are exposed to a higher risk of injury and delay diagnosis due to the abnormal anatomy. We report two cases of acute traumatic craniocervical dislocation in patients with baseline congenital assimilation of the atlas to the skull. Computer tomography (CT) was used to identify the injury. Computer tomography angiography (CTA) showed variations of the vertebral arteries' location on both patients. Assimilation of the atlas was complete in patient one and partial in patient two. Emergent surgical instrumentation and fusion were performed with a very careful and meticulous posterior dissection. As general rule, most of the patients with CCD will undergo occiput to C2 posterior segmental instrumentation and fusion. In the presented cases, a more extensive fusion was necessary based on the type and severity of the CCJ injury and the anatomical anomalies associated. Postoperatively, patient one remained neurologically intact and patient two died. Alternative fixation techniques should be used to minimize risk of VA injury during the surgical procedures.

Is routine MRI of the spine necessary in trauma patients with ankylosing spinal disorders or is a CT scan sufficient?

BACKGROUND: Ankylosing spinal disorder (ASD) patients are at a greater risk for spinal fractures due to osteoporosis and rigidity of the spinal column. These fractures are associated with a high risk of neurologic compromise resulting from delayed or missed diagnoses. Although computed tomography (CT) is usually the initial imaging modality, magnetic resonance imaging (MRI) has been proposed as mandatory to help identify spinal injuries in ASD patients with unexplained neck or back pain or known injuries to help identify noncontiguous fractures. However, some studies have also shown that neurological injury can result from the required patient transfer and positioning for an MRI. PURPOSE: The purpose of our study was to assess the frequency with which an MRI identified an injury not previously identified with CT, and whether this affected the treatment and outcome of the patient. Secondarily, we attempted to identify clinical or CT findings that may render an MRI particularly useful. STUDY DESIGN: Retrospective review. PATIENT SAMPLE: Patients with ASD who sustained acute spine fractures from 2005 to 2015. OUTCOME MEASURES: Acute fractures identified by CT scan and MRI upon admission; neurologic status upon admission and discharge, mode of injury, type of fracture, and final intervention before and after MRI assessment. METHODS: A total of 124 patients with a diagnosis of diffuse idiopathic skeletal hyperostosis (DISH) or ankylosing spondylitis (AS) were identified by searching the radiology database of a level I trauma center with diagnosis keywords. Final radiology reports were assessed to determine presence and type of fracture(s) from CT. MRI report was then reviewed to assess if additional fractures or injuries were identified beyond that already known from the CT. Neurologic status upon admission and discharge, mode of injury, type of fracture, and final intervention were determined by inpatient notes and/or operative reports. No source funding or conflict of interest was present pertaining to this study. RESULTS: In the designated time frame, 124 ASD patients with injuries of the spine were identified who had obtained both a baseline CT and MRI. Six patients (4.8%) had additional injuries on MRI that had not been identified with CT. Four of these six patients had a change in treatment plan (three operative and one nonoperative) based on subsequent MRI findings. These included a (1) C4-5 hyperextension injury, (2) C6-7 hyperextension injury, (3) C7 bony fracture with C5-T4 epidural hematoma, and (4) C5-C6 hyperextension injury treated in a brace. Two of the six patients that had additional injuries identified on MRI had no change in their treatment plan. One patient had an additional lumbar extension injury identified above a previously diagnosed injury on CT, which was managed with a Thoracolumbosacral Orthosis (TLSO) according to the original plan. One patient died who had a known odontoid fracture and a suspected C6-7 hyperextension injury, and was identified on MRI as also having a C3-C4 hyperextension injury and a C2 spinal cord transection. CONCLUSIONS: In this study, 3.2% (4/124) of patients with ASD who presented to a level I trauma center with an acute spine injury identified with CT required a change in their treatment plan based on subsequent MRI findings. Only one fracture was missed on CT imaging, with the other missed injuries all being either disco-ligamentous hyperextension injuries through mobile discs or intracanal pathology. Our recommendation is that the routine use of MRI be limited to patients with nonankylosed levels in which a disco-ligamentous injury may have occurred, and in patients with neurological deficits that require investigation of the spinal canal to assess for causes of neurological injury.

The impact of stenosis and translation on spinal cord injuries in traumatic cervical facet dislocations.

BACKGROUND CONTEXT: Although facet dislocations account for only 6% of cervical trauma, the consequences are often devastating. Cervical facet dislocations are associated with a disproportionate amount of spinal cord injuries; however, neurologic examination of patients is often difficult, as patients commonly present with reduced levels of consciousness. There are limited studies that have investigated the impact of spinal canal diameter and translation on neurologic injury following facet dislocations. PURPOSE: Review a consecutive series of patients with facet dislocations to assess the impact of sagittal diameter and translation on Spinal Cord Injury (SCI). STUDY DESIGN: Retrospective review at a level I trauma center identified 97 patients with facet dislocations. METHODS: Between 2004 and 2014, a retrospective review at a level I trauma center identified patients with traumatic facet dislocation. Demographic data, neurologic exams, and radiographic findings were reviewed. We assessed sagittal diameter at the injury level, as well as above and below, and translation. This study has no funding source and its authors have no potential conflicts of interest-associated biases. RESULTS: Ninety-seven patients presented with facet dislocations. Fifty-nine (61%) presented with a SCI. Those with ASIA A averaged 8.0 mm of injury level canal diameter, and ASIA E averaged 12.6 mm (p < .001). Additionally, those with ASIA A averaged 8.0 mm of translation, and ASIA E averaged 4.2 mm (p < 0.001). Two groups were created based on their general motor function. Those with ASIA A-C averaged 8.4 mm of injury level canal diameter, and ASIA D-E averaged 12.3 mm (p < .001). Those with ASIA A-C averaged 7.8 mm of translation, and ASIA D-E averaged 4.4 mm (p < .001). Receiver operating characteristic (ROC) curves demonstrated that translation was a good predictor of ASIA A-C and canal diameter was an almost perfect predictor of ASIA D-E. CONCLUSIONS: Our data indicate that patients with greater translation and/or a smaller canal diameter at the injury level have a higher rate of SCI. Adjacent canal diameter did not correlate with neurologic injury.

Body mass index and the risk of deep surgical site infection following posterior cervical instrumented fusion.

BACKGROUND: Surgical site infection (SSI) following spine surgery is associated with increased morbidity, reoperation rates, hospital readmissions, and cost. The incidence of SSI following posterior cervical spine surgery is higher than anterior cervical spine surgery, with rates from 4.5% to 18%. It is well documented that higher body mass index (BMI) is associated with increased risk of SSI after spine surgery. There are only a few studies that examine the correlation of BMI and SSI after posterior cervical instrumented fusion (PCIF) using national databases, however, none that compare trauma and nontraumatic patients. PURPOSE: The purpose of this study is to determine the odds of developing SSI with increasing BMI after PCIF, and to determine the risk of SSI in both trauma and nontraumatic adult patients. STUDY DESIGN: This is a retrospective cohort study of a prospective surgical database collected at one academic institution. PATIENT SAMPLE: The patient sample is from a prospectively collected surgical registry from one institution, which includes patients who underwent PCIF from April 2011 to October 2017. OUTCOME MEASURES: A SSI that required return to the operating room for surgical debridement. METHODS: This is a retrospective cohort study using a prospectively collected database of all spine surgeries performed at our institution from April 2011 to October 2017. We identified 1,406 patients, who underwent PCIF for both traumatic injuries and nontraumatic pathologies using International Classification of Diseases 9 and 10 procedural codes. Thirty-day readmission data were obtained. Patient's demographics, BMI, presence of diabetes, preoperative diagnosis, and surgical procedures performed were identified. Using logistic regression analysis, the risk of SSI associated with every one-unit increase in BMI was determined. This study received no funding. All the authors in this study report no conflict of interests relevant to this study. RESULTS: Of the 1,406 patients identified, 1,143 met our inclusion criteria. Of those patients, 688 had PCIF for traumatic injuries and 454 for nontraumatic pathologies. The incidence of SSI for all patients, who underwent PCIF was 3.9%. There was no significant difference in the rate of SSI between our trauma group and nontraumatic group. There was a higher rate of infection in patients, who were diabetic and with BMI≥30 kg/m2. The presence of both diabetes and BMI≥30 kg/m2 had an added effect on the risk of developing SSI in all patients, who underwent PCIF. Additionally, logistic regression analysis showed that there was a positive difference measure between BMI and SSI. Our results demonstrate that for one-unit increase in BMI, the odds of having a SSI is 1.048 (95% CI: 1.007-1.092, p=.023). CONCLUSIONS: Our study demonstrates that our rate of SSI after PCIF is within the range of what is cited in the literature. Interestingly, we did not see a statistically significant difference in the rate of infection between our trauma and nontrauma group. Overall, diabetes and elevated BMI are associated with increased risk of SSI in all patients, who underwent PCIF with even a higher risk in patient, who are both diabetic and obese. Obese patients should be counseled on elevated SSI risk after PCIF, and those with diabetes should be medically optimized before and after surgery when possible to minimize SSI.

Enhanced Perioperative Care for Major Spine Surgery.

STUDY DESIGN: The enhanced perioperative care (EPOC) program is an institutional quality improvement initiative. We used a historically controlled study design to evaluate patients who underwent major spine surgery before and after the implementation of the EPOC program. OBJECTIVE: To determine whether multidisciplinary EPOC program was associated with an improvement in clinical and financial outcomes for elective adult major spine surgery patients. SUMMARY OF BACKGROUND DATA: The enhanced recovery after surgery (ERAS) programs successfully implemented in hip and knee replacement surgeries, and improved clinical outcomes and patient satisfaction. METHODS: We compared 183 subjects in traditional care (TRDC) group to 267 intervention period (EPOC) in a single academic quaternary spine surgery referral center. One hundred eight subjects in no pathway (NOPW) care group was also examined to exclude if the observed changes between the EPOC and TRDC groups might be due to concurrent changes in practice or population over the same time period. Our primary outcome variables were hospital and intensive care unit lengths of stay and the secondary outcomes were postoperative complications, 30-day hospital readmission and cost. RESULTS: In this highly complex patient population, we observed a reduction in mean hospital length of stay (HLOS) between TRDC versus EPOC groups (8.2 vs. 6.1 d, standard deviation [SD] = 6.3 vs. 3.6, P < 0.001) and intensive care unit length of stay (ILOS) (3.1 vs. 1.9 d, SD = 4.7 vs. 1.4, P = 0.01). The number (rate) of postoperative intensive care unit (ICU) admissions was higher for the TRDC n = 109 (60%) than the EPOC n = 129 (48%) (P = 0.02). There was no difference in postoperative complications and 30-day hospital readmissions. The EPOC spine program was associated with significant average cost reduction-$62,429 to $53,355 (P < 0.00). CONCLUSION: The EPOC program has made a clinically relevant contribution to institutional efforts to improve patient outcomes and value. We observed a reduction in HLOS, ILOS, costs, and variability. LEVEL OF EVIDENCE: 3.

Predictors of increased cost and length of stay in the treatment of postoperative spine surgical site infection.

BACKGROUND CONTEXT: Although many risk factors are known to contribute to the development of a postoperative surgical site infection (SSI) following spinal surgery, little is known regarding the costs associated with the management of this complication, or the predictors for which patients will require increased resources for the management of SSI. PURPOSE: The aim of this study was to identify specific risk factors for increased treatment costs and length of stay in the management of a postoperative SSI. STUDY DESIGN/SETTING: This is a retrospective cohort study of all patients undergoing spine surgery at a single institution for 3 consecutive years. PATIENT SAMPLE: The study included 90 patients who were required to return to the operating room following spine surgery for postoperative SSI. OUTCOME MEASURES: The primary outcome measure was length of stay and hospital costs for patients with postoperative SSI following spine surgery at a single institution. METHODS: A retrospective review of all patients undergoing spine surgery at a single institution for 3 consecutive years was performed to identify patients requiring secondary surgical intervention for SSI. Demographic and financial data from both the index admission and all subsequent readmissions within 2 years of the index procedure were reviewed. Independent variables abstracted from patient records were analyzed to determine the nature and the extent of their associations with total direct hospital costs and length of stay. RESULTS: A total of 90 patients were identified that resulted in 110 readmissions, and these patients cumulatively underwent 138 irrigation and debridement (I&D) procedures for the management of postoperative spine SSI. The average length of stay for the index operation and secondary readmissions were 6.9 and 9.6 days, respectively. The mean direct cost of the treatment for SSI was $16,242. The length of stay, the number of levels fused, methicillin-resistant Staphylococcus aureus (MRSA), decreased serum albumin on readmission, and the number of I&D procedures required were significantly associated with increased treatment costs. CONCLUSIONS: Preoperative nutritional status assessment and MRSA colonization screening with targeted prophylaxis represent potentially modifiable risk factors in the treatment of SSI. Further study is needed to investigate the relationship between poor nutrition status and increased length of stay and total costs in the treatment of SSI following spine surgery.