Thoracolumbar Injury Classification and Severity Score Is Predictive of Perioperative Adverse Events in Operatively Treated Thoracic and Lumbar Fractures

Methods@#We performed a retrospective review of 199 patients with surgically treated thoracolumbar fractures operated between January 2007 and January 2018. The potential risk factors for the development of AEs as well as the development of common complications were evaluated by univariate analysis, and a multivariate logistic regression analysis was performed to identify independent risk factors predictive of the above. @*Results@#The overall rate of AEs was 46.7%; 83 patients (41.7%) had nonsurgical AEs, whereas 24 (12.1%) had surgical adverse events. The most common AEs were urinary tract infections in 43 patients (21.6%), and hospital-acquired pneumonia in 21 patients (10.6%). On multivariate logistic regression, a Thoracolumbar Injury Classification and Severity (TLICS) score of 8–10 (odds ratio [OR], 6.39; 95% confidence interval [CI], 2.33–17.51), the presence of polytrauma (OR, 2.64; 95% CI, 1.17–5.99), and undergoing open surgery (OR, 2.31; 95% CI, 1.09–4.88) were significant risk factors for AEs. The absence of neurological deficit was associated with a lower rate of AEs (OR, 0.47; 95% CI, 0.31–0.70). @*Conclusions@#This study suggests the presence of polytrauma, preoperative American Spinal Injury Association score, and TLICS score are predictive of AEs in patients with surgically treated thoracolumbar fractures. The results might also suggest a role for minimally invasive surgical methods in reducing AEs in these patients.

Symptomatic Construct Failure after Metastatic Spine Tumor Surgery

Methods@#We conducted a retrospective analysis on 288 patients (246 for final analysis) who underwent MSTS between 2005–2015. Data collected were demographics and peri/postoperative clinical and radiological features. Early and late radiological SF were defined as presentation before and after 3 months from index surgery, respectively. Univariate and multivariate models of competing risk regression analysis were designed to determine the risk factors for SF with death as a competing event. @*Results@#We observed 14 SFs (5.7%) in 246 patients; 10 (4.1%) underwent revision surgery. Median survival was 13.4 months. The mean age was 58.8 years (range, 21–87 years); 48.4% were women. The median time to failure was 5 months (range, 1–60 months). Patients with SF were categorized into three groups: (1) SF when the primary implant was revised (n=5, 35.7%); (2) peri-construct progression of disease requiring extension (n=5, 35.7%); and (3) SFs that did not warrant revision (n=4, 28.5%). Four patients (28.5%) presented with early failure. SF commonly occurred at the implant-bone interface (9/14) and all patients had a spinal instability neoplastic score (SINS) >7. Thirteen patients (92.8%) who developed failure had fixation spanning junctional regions. Multivariate competing risk regression showed that preoperative Eastern Cooperative Oncology Group score was a significant risk factor for implant failure (adjusted sub-hazard ratio, 7.0; 95% confidence interval, 1.63–30.07; p7 and fixations spanning junctional regions were associated with SF. Majority of construct failures occurred at the implant-bone interface.

Symptomatic Construct Failure after Metastatic Spine Tumor Surgery

Methods@#We conducted a retrospective analysis on 288 patients (246 for final analysis) who underwent MSTS between 2005–2015. Data collected were demographics and peri/postoperative clinical and radiological features. Early and late radiological SF were defined as presentation before and after 3 months from index surgery, respectively. Univariate and multivariate models of competing risk regression analysis were designed to determine the risk factors for SF with death as a competing event. @*Results@#We observed 14 SFs (5.7%) in 246 patients; 10 (4.1%) underwent revision surgery. Median survival was 13.4 months. The mean age was 58.8 years (range, 21–87 years); 48.4% were women. The median time to failure was 5 months (range, 1–60 months). Patients with SF were categorized into three groups: (1) SF when the primary implant was revised (n=5, 35.7%); (2) peri-construct progression of disease requiring extension (n=5, 35.7%); and (3) SFs that did not warrant revision (n=4, 28.5%). Four patients (28.5%) presented with early failure. SF commonly occurred at the implant-bone interface (9/14) and all patients had a spinal instability neoplastic score (SINS) >7. Thirteen patients (92.8%) who developed failure had fixation spanning junctional regions. Multivariate competing risk regression showed that preoperative Eastern Cooperative Oncology Group score was a significant risk factor for implant failure (adjusted sub-hazard ratio, 7.0; 95% confidence interval, 1.63–30.07; p7 and fixations spanning junctional regions were associated with SF. Majority of construct failures occurred at the implant-bone interface.

In the Extraordinary Times of Coronavirus Disease 2019: Clinical Strategies for Performing Spinal Surgery

The coronavirus disease 2019 (COVID-19) pandemic has caused pronounced strain on global healthcare systems, forcing the streamlining of clinical activities and conservation of health resources. There is a pressing need for institutions to present discipline-specific strategies for the management of COVID-19 patients. We present the comprehensive considerations at the National University Hospital, Singapore from the surgeon’s and anesthetist’s perspectives in the performance of spinal surgery in COVID-19 patients. These are based on national guidelines and overarching principles of protection for the healthcare workers (HCWs) and efficiency in surgical planning. The workflow begins with the emergency department screening that has been adapted to the local epidemiology of COVID-19 in order to identify suspected/confirmed cases. If patient history cannot be obtained, demographic, clinical, and imaging data are used. Designated orthopedic “contaminated teams” are available 24/7 with an activation time of

Clinical outcomes of single-level lumbar artificial disc replacement compared with transforaminal lumbar interbody fusion in an Asian population

<p><b>INTRODUCTION</b>The objective of this study was to examine the clinical outcome of single-level lumbar artificial disc replacement (ADR) compared to that of transforaminal lumbar interbody fusion (TLIF) for the treatment of symptomatic degenerative disc disease (DDD) in an Asian population.</p><p><b>METHODS</b>This was a retrospective review of 74 patients who had surgery performed for discogenic lower backs that involved only the L4/5 and L5/S1 levels. All the patients had lumbar DDD without radiculopathy or spondylolithesis, and concordant pain with discogram at the pathological level. The patients were divided into two groups--those who underwent ADR and those who underwent TLIF.</p><p><b>RESULTS</b>A trend suggesting that the ADR group had better perioperative outcomes (less blood loss, shorter operating time, shorter hospital stay and shorter time to ambulation) than the TLIF group was observed. However, a trend indicating that surgical-approach-related complications occurred more frequently in the ADR group than the TLIF group was also observed. The rate of revision surgery was comparable between the two groups.</p><p><b>CONCLUSION</b>Our findings suggest that for the treatment of discogenic lower back pain, lumbar ADR has better perioperative outcomes and a similar revision rate when compared with TLIF. However, the use of ADR was associated with a higher incidence of surgical-approach-related complications. More studies with bigger cohort sizes and longer follow-up periods are needed to determine the long-term efficacy and safety of ADR in lumbar DDD.</p>

Trans-iliosacral plating for vertically unstable fractures of sacral spine associated with spinopelvic dissociation: A cadaveric study.

BACKGROUND: The treatment algorithm for sacral fracture associated with vertical shear pelvic fracture has not emerged. Our aim was to study a new approach of fixation for comminuted and vertically unstable fracture pattern with spinopelvic dissociation to overcome inconsistent outcome and avoid complications associated with fixations. We propose fixation with well-contoured thick reconstruction plate spreading across sacrum from one iliac bone to another with fixation points in iliac wing, sacral ala and sacral pedicle on either side. Present biomechanical study tests the four fixation pattern to compare their stiffness to vertical compressive forces. MATERIALS AND METHODS: Dissection was performed on human cadavers through posterior midline paraspinal approach elevating erector spinae from insertion with two flaps. Feasibility of surgical exposure and placement of contoured plate for fixation was evaluated. Ten age and sex matched computed tomography scans of pelvis with both hips were obtained. Reconstructions were performed with advantage windows 4.2 (GE Light Speed QX/I, General Electric, Milwaukee, WI, USA). Using the annotation tools, direct digital CT measurement (0.6 mm increments) of three linear parameters was carried out. Readings were recorded at S2 sacral level. Pelvic CT scans were extensively studied for entry point, trajectory and estimated length for screw placement in S2 pedicle, sacral ala and iliac wing. Readings were recorded for desired angulation of screw in iliac wing ala of sacrum and sacral pedicle with respect to midline. The readings were analyzed by the values of mean and standard deviation. Biomechanical efficacy of fixation methods was studied separately on synthetic bone. Four fixation patterns given below were tested to compare their stiffness to vertical compressive forces: 1) Single S1 iliosacral screw (7.5 mm cancellous screw), 2) Two S1 and S2 iliosacral screws, 3) Isolated trans-iliosacral plate, 4) Trans-iliosacral plate + single S1 iliosacral screw. STATISTICAL ANALYSIS: Mean of desired angulation for inserting screws and percentage of displacement on biomechanical testing was evaluated. RESULTS: Mean angulations for inserting sacral pedicel were 12.3° (SD 2.7°) convergent to midline and divergent of 14° (SD 2.3°) for sacral ala screw and 23° (SD 4.9°) for iliac wing screw. All screws needed to be inserted at an angle of 90° to sacral dorsum to avoid violation of root canals. Cross headed displacement across fracture site was measured and plotted against the applied vertical shear load of 300 N in five cycles each for all the four configurations. Also, the force required for cross headed displacement of 2.5 mm and 5 mm was recorded for all configurations. Transmitted load across both ischial tuberosities was measured to resolve unequal distribution of forces. Taking one screw construct (configuration 1) as standard base reference, trans-iliosacral plate construct (configuration 3) showed equal rigidity to standard reference. Two screw construct (configuration 2) was 12% stronger and trans-iliosacral plate (configuration 4) with screw was 9% stronger at 2.5 mm displacing on 300 N force, while it showed 30% and 6%, respectively, at 5 mm cross-headed displacement. CONCLUSIONS: Trans-iliosacral plating is feasible anatomically, biomechanically and radiologically for sacral fractures associated with vertical shear pelvic fractures. Low profile of plate reduces the risk of hardware prominence and decreases the need for implant removal. Also, the fixation pattern of plate allows to spare mobile lumbosacral junction which is an important segment for spinal mobility. Biomechanical studies revealed that rigidity offered by plate for cross headed displacement across fracture site is equal to sacroiliac screws and further rigidity of construct can be increased with addition of one more screw. There is need for precountered thicker plate in future.

Epidemiological analysis of outcomes in 323 open tibial diaphyseal fractures: a nine-year experience

<p><b>INTRODUCTION</b>Open fractures of the tibia pose a challenge to orthopaedic and plastic surgeons. A retrospective observational review was conducted to evaluate the epidemiological factors and fracture outcomes in the Singapore context.</p><p><b>METHODS</b>A nine-year period of open tibial shaft fractures presenting to our institution was reviewed. Demographic and management data were recorded. Statistical analysis was performed on the outcomes of length of hospital stay, number of operations, time to union and infection rates.</p><p><b>RESULTS</b>323 fractures met our inclusion criteria (Gustilo [G] 1=53, G2=100, G3=170). Mean age of patients was 36.5 years, 91.3% were male and 40.9% were non-Singaporeans. 69.3% of fractures occurred from road traffic accidents and 21.7% from industrial accidents. Mean length of hospital stay was 28.7 days and number of operations was 4.29. Time to union was 10.7 months and overall infection rate was 20.7%. Infection rates were significantly higher in G3b/G3c compared to G3a (45.7% vs. 21.1%) patients. There was no significant reduction in infection rates when open tibial fractures were operated on within six hours of admission. Multiple injured patients required a longer time to union and hospital stay. There was an exponential cost increase with greater severity of fracture.</p><p><b>CONCLUSION</b>High Gustilo and AO classification injuries positively correlate with high non-union and infection rates, requiring multiple operations and long hospital stay. There is no benefit in performing surgery on open tibial fractures within six hours of presentation. A significant proportion of these patients would be polytraumatised, indirectly affecting fracture union.</p>