Clinical Relevance of Painful Congenital Early-onset Scoliosis: A Magnetic Resonance Image-based Study.

BACKGROUND: Back pain, as a clinical marker in scoliosis, has been associated with underlying pathology for many years, warranting further magnetic resonance imaging (MRI). Failures of segmentation, mixed defects, female gender, rib anomalies, congenital thoracic anomalies, and neurocutaneous markers are known risk factors for abnormal MRI pathology findings in patients with congenital early-onset scoliosis (Congenital-EOS). Yet, back pain has not been evaluated as a risk factor for underlying MRI pathology in patients with Congenital-EOS. This study aimed to assess back pain as a risk factor for underlying pathology in Congenital-EOS using MRI as a diagnostic tool. METHODS: A retrospective database review from the Pediatric Spine Study Group (PSSG) of all patients with Congenital-EOS who reported a back pain complaint, and underwent a spinal MRI study before surgical intervention was performed. Patients were divided into those with an underlying MRI pathology and those without. Demographics were compared between groups. RESULTS: From a total of 2355 patients with Congenital-EOS registered in PSSG, 107 patients reported a back pain complaint, with only 42 patients fulfilling the inclusion criteria (being evaluated with an MRI study). Overall group mean age was 8.1±4.5 years, with 25 of the 42 patients (60%) being females. Twenty-four of 42 patients (57%) had a comorbidity reported such as cardiac problems, musculoskeletal complaints, neurological deficits/myelopathy, gastrointestinal symptoms, developmental delay, respiratory problems, craniofacial abnormalities, and chromosomal conditions. An underlying MRI pathology was found in 21 of 42 patients with Congenital-EOS (50%) with back pain. The underlying MRI pathologies found were tethered spinal cord, spinal canal stenosis, syringomyelia, Arnold-Chiari malformation, and arachnoid cyst. CONCLUSIONS: Abnormal MRI findings are common in patients with Congenital-EOS who report back pain. Gender, age, major coronal curve angle, thoracic or lumbar predominance deformity, and comorbidities type or amount were not associated with abnormal MRI findings. LEVEL OF EVIDENCE: Level II-Prognostic study.

Proteomic Portraits Reveal Evolutionarily Conserved and Divergent Responses to Spinal Cord Injury.

Despite the emergence of promising therapeutic approaches in preclinical studies, the failure of large-scale clinical trials leaves clinicians without effective treatments for acute spinal cord injury (SCI). These trials are hindered by their reliance on detailed neurological examinations to establish outcomes, which inflate the time and resources required for completion. Moreover, therapeutic development takes place in animal models whose relevance to human injury remains unclear. Here, we address these challenges through targeted proteomic analyses of cerebrospinal fluid and serum samples from 111 patients with acute SCI and, in parallel, a large animal (porcine) model of SCI. We develop protein biomarkers of injury severity and recovery, including a prognostic model of neurological improvement at 6 months with an area under the receiver operating characteristic curve of 0.91, and validate these in an independent cohort. Through cross-species proteomic analyses, we dissect evolutionarily conserved and divergent aspects of the SCI response and establish the cerebrospinal fluid abundance of glial fibrillary acidic protein as a biochemical outcome measure in both humans and pigs. Our work opens up new avenues to catalyze translation by facilitating the evaluation of novel SCI therapies, while also providing a resource from which to direct future preclinical efforts.

Attention-gated U-Net networks for simultaneous axial/sagittal planes segmentation of injured spinal cords.

Magnetic resonance imaging is currently the gold standard for the evaluation of spinal cord injuries. Automatic analysis of these injuries is however challenging, as MRI resolutions vary for different planes of analysis and physiological features are often distorted around these injuries. This study proposes a new CNN-based segmentation method in which information is exchanged between two networks analyzing the scans from different planes. Our aim was to develop a robust method for automatic segmentation of the spinal cord in patients having suffered traumatic injuries. The database consisted of 106 sagittal MRI scans from 94 patients with traumatic spinal cord injuries. Our method used an innovative approach where the scans were analyzed in series under the axial and sagittal plane by two different convolutional networks. The results were compared with those of Deepseg 2D from the Spinal Cord Toolbox (SCT), which was taken as state-of-the-art. Comparisons were evaluated using K-Fold cross-validation combined with statistical t-test results on separate test data. Our method achieved significantly better results than Deepseg 2D, with an average Dice coefficient of 0.95 against 0.88 for Deepseg 2D (p <0.001). Other metrics were also used to compare the segmentations, all of which showed significantly better results for our approach. In this study, we introduce a robust method for spinal cord segmentation which is capable of adequately segmenting spinal cords affected by traumatic injuries, improving upon the methods contained in SCT.

Optoelectronic Pressure Sensor Based on the Bending Loss of Plastic Optical Fibers Embedded in Stretchable Polydimethylsiloxane.

We report the design and testing of a sensor pad based on optical and flexible materials for the development of pressure monitoring devices. This project aims to create a flexible and low-cost pressure sensor based on a two-dimensional grid of plastic optical fibers embedded in a pad of flexible and stretchable polydimethylsiloxane (PDMS). The opposite ends of each fiber are connected to an LED and a photodiode, respectively, to excite and measure light intensity changes due to the local bending of the pressure points on the PDMS pad. Tests were performed in order to study the sensitivity and repeatability of the designed flexible pressure sensor.

Is quality of life after surgery for adolescent idiopathic scoliosis affected by the presence of a concomitant low-grade isthmic spondylolisthesis non-surgically treated? A retrospective cohort study.

PURPOSE: The HRQoL after surgery for adolescent idiopathic scoliosis (AIS) is not affected by the presence of concomitant isthmic spondylolisthesis non-surgically treated. Improvement in QoL after surgery was similar for AIS patients with and without concomitant spondylolisthesis. The purpose is to compare preoperative and postoperative Health-Related Quality of Life (HRQoL) scores in operated AIS patients with and without concomitant isthmic spondylolisthesis. METHODS: A retrospective study of a prospective cohort of 464 individuals undergoing AIS surgery between 2008 and 2018 was performed. All patients undergoing surgery for AIS with a minimum 2-year follow-up were included. We excluded patients with prior or concomitant surgery for spondylolisthesis. HRQoL scores were measured using the SRS-22 questionnaire. Comparisons were performed between AIS patients with versus without concomitant spondylolisthesis treated non-surgically. RESULTS: AIS surgery was performed for 36 patients (15.2 ± 2.5 y.o) with concomitant isthmic spondylolisthesis, and 428 patients (15.5 ± 2.4 y.o) without concomitant spondylolisthesis. The two groups were similar in terms of age, sex, preoperative and postoperative Cobb angles. Preoperative and postoperative HRQoL scores were similar between the two groups. HRQoL improved significantly for all domains in both groups, except for pain in patients with spondylolisthesis. There was no need for surgical treatment of the spondylolisthesis and no slip progression during the follow-up duration after AIS surgery. CONCLUSION: Patients undergoing surgical treatment of AIS with non-surgical management of a concomitant isthmic grade I spondylolisthesis can expect improvement in HRQoL scores, similar to that observed in patients without concomitant spondylolisthesis.

Assessing head acceleration to identify a motor threshold to galvanic vestibular stimulation.

Galvanic vestibular stimulation (GVS) is used to assess vestibular system function, but vestibulospinal responses can exhibit variability depending on protocols or intensities used. Here, we measured head acceleration in healthy subjects to identify an objective motor threshold on which to base GVS intensity when assessing standing postural responses. Thirteen healthy right-handed subjects stood on a force platform, eyes closed, and head facing forward. An accelerometer was placed on the vertex to detect head acceleration, and electromyography activity of the right soleus was recorded. GVS (200 ms; current steps 0.5, from 1 mA to 4 mA) was applied in a binaural and bipolar configuration. 1) GVS induced a biphasic accelerometer response at a latency of 15 ms. Based on response amplitude, we constructed a recruitment curve for all participants and determined the motor threshold. In parallel, the method of limits was used to devise a more rapid approach to determine motor threshold. 2) We observed significant differences between motor threshold based on a recruitment curve and all perceptual thresholds reported either by the subject (sensation of movement) or a standing experimenter observing the participant (perception of movement). No significant difference was observed between the motor threshold based on the method of limits and perceptual thresholds of movement. 3) Using orthogonal polynomial contrasts, we observed a linear progression between multiples of the objective motor threshold (0.5, 0.75, 1, 1.5× motor threshold) and the 95% confidence ellipse area, the first peak of center of pressure displacement velocity, and the short and medium latency responses in the soleus. Hence, an objective motor threshold for GVS based on head acceleration was identified in standing participants and a recruitment curve could be constructed for all participants. These novel approaches could enable better understanding of changes in the vestibular system in different conditions or over time.NEW & NOTEWORTHY Galvanic vestibular stimulation (GVS) has been used to assess the vestibular system, but the significant interindividual variability in the responses makes it difficult to quantitatively compare them between individuals or conditions. Using an accelerometer to quantify head movement induced by GVS, we were able to determine an objective motor threshold and construct a recruitment curve for all participants. These methods could help assess changes in the vestibular system under different conditions.

Patient outcomes in idiopathic scoliosis are associated with biological endophenotypes: 2020 SOSORT award winner.

PURPOSE: Bracing is the treatment of choice for idiopathic scoliosis (IS), unfortunately factors underlying brace response remain unknown. Clinicians are currently unable to identify patients who may benefit from bracing, and therefore, better molecular stratification is critically needed. The aim of this study is to evaluate IS patient outcomes at skeletal maturity in relation to biological endophenotypes, and determine specific endophenotypes associated to differential bracing outcomes. This is a retrospective cohort with secondary cross-sectional comparative studies. METHODS: Clinical and radiological data were collected from 563 IS patients, stratified into biological endophenotypes (FG1, FG2, FG3) based on a cell-based test. Measured outcomes were maximum Cobb angle at skeletal maturity, and if severe, spinal deformity (≥ 45°) or surgery was attained. Treatment success/failure was determined by standard progression thresholds (Cobb ≥ 45° or surgery; Cobb angle progression ≥ 6°). Multivariable analyses were performed to evaluate associations between endophenotypes and clinical outcome. RESULTS: Higher Cobb angles at maturity for FG1 and FG2 patients were observed (p = 0.056 and p = 0.05), with increased likelihood of ≥ 45° and/or surgery for FG1 (OR = 2.181 [1.002-4.749] and FG2 (OR = 2.141 [1.038-4.413]) compared to FG3. FG3 was 9.31 [2.58-33.61] and 5.63 [2.11-15.05] times more likely for bracing success at treatment termination and based on the < 6° progression criterion, respectively, compared to FG1. CONCLUSION: Associations between biological endophenotypes and outcomes suggest differences in progression and/or bracing response among IS patients. Outcomes were most favorable in FG3 patients. The results pave the way for establishing personalized treatments, distinguishing who may benefit or not from treatment.

Factors associated with discharge destination following inpatient functional rehabilitation in patients with traumatic spinal cord injury.

STUDY DESIGN: Retrospective review of data from a prospective database of a Level 1 trauma center. OBJECTIVES: This project aims to identify factors collected during the acute and rehabilitative care following a traumatic spinal cord injury (TSCI) associated with success and failure to return home after inpatient intensive functional rehabilitation (IFR). SETTING: Level 1 trauma center specialized in TSCI care in Montreal, Canada. METHODS: All eligible patients from our prospective database were separated into two groups according to discharge destination following IFR. Clinical variables collected during the acute and rehabilitative care as well as demographic variables were compared between patients who managed to return home (Group 1) and those who were discharged elsewhere (Group 2). Multivariable regression analyses were conducted with variables that were significant at the univariate level. RESULTS: Out of the 193 patients included, 22 (11%) failed to return home following IFR. Six variables were associated with failure to return home at the univariate level: longer acute length of stay (LOS), longer rehabilitation LOS, living alone, higher neurological level of injury, having comorbidities, and having a pressure injury (PI) during acute care. Three variables remained significant at the multivariate level: living alone, increasing acute LOS and presenting a high cervical (C1-C4) neurological level of injury. CONCLUSIONS: It is important that acute care clinicians recognize the aforementioned factors early after TSCI in order to optimize patients for community reintegration.

Are early clinical manifestations of spasticity associated with long-term functional outcome following spinal cord injury? A retrospective study.

STUDY DESIGN: Retrospective study of a prospective cohort of patients with traumatic spinal cord injury (SCI). OBJECTIVES: Determine the relationship between the occurrence of early spasticity, defined as the development of signs and/or symptoms of spasticity during the hospitalization in traumatology, and the functional outcome 6-12 months following a SCI. Secondly, to determine the specific impact of early clonus, velocity-dependent hypertonia and/or muscle spasms on the functional outcome at the same timepoint. SETTING: Single trauma center specialized in SCI care. METHODS: One hundred sixty-two patients sustaining an acute traumatic SCI were included in the analyses. Comparative analysis was performed to describe the characteristics of patients with early spasticity. Correlations were performed to determine the relationship between the clinical signs of spasticity and the Spinal Cord Independence Measure (SCIM) scores collected 6-12 months after SCI. RESULTS: 51.9% of the cohort developed clinical signs of spasticity during the hospitalization in traumatology (29.7 days) following SCI. These showed a significantly lower total SCIM score and subscores compared to individuals without early spasticity at follow-up (p < 0.05). After adjusting for confounding factors, the occurrence of early spasms was only clinical sign of spasticity significantly associated with a decreased mobility at follow-up (r = -0.17, p = 0.04). CONCLUSIONS: The development of signs and symptoms of spasticity, in particular the occurrence of spasms in the first month following the injury may be associated with decreased functional outcome and mobility. Early assessment of spasticity following SCI is thus recommended.

An evaluation of the representativeness of a national spinal cord injury registry: a population-based cohort study.

STUDY DESIGN: Population-based cohort study for the western part of Quebec. OBJECTIVES: To determine the impact of declining to participate in a national spinal cord injury (SCI) registry on patient outcomes and continuum of care. SETTING: Level-1 trauma center specialized in SCI care in Montreal, Canada. METHODS: This cohort study compared the outcomes of 444 patients who were enrolled in the Rick Hansen SCI registry and 140 patients who refused. Logistic regression analyses were performed to assess the association between voluntary participation and the outcomes, while adjusting for confounding factors. The main outcomes were: attendance to follow-up 6- to 12-month post injury, 1-year mortality, and the occurrence of pressure injury during acute care. RESULTS: Declining to be enrolled in the registry was a significant predictor of lower attendance to specialized follow-up (adjusted odds ratio [OR] 0.04, 95% confidence interval [CI] 0.02-0.08). It was also associated with a higher 1-year mortality rate (OR 12.50, CI 4.50-33.30) and higher occurrence of pressure injury (OR 2.56, CI 1.56-4.17). CONCLUSIONS: This study sheds invaluable insight on individuals that researchers and clinicians are usually blind to in SCI cohort studies. This study suggests that decline to participate in a registry during the care hospitalization may be associated with worsened health, poorer outcomes, and reduced follow-up to specialized care. Declining the enrollment to voluntary registry could represent a potential prognostic factor for future research.

Clinical judgment is a cornerstone for validating and using clinical prediction rules: a head-to-head study on ambulation outcomes for spinal cord injured patients.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: Clinical prediction rules (CPRs) are an effervescent topic in the medical literature. Recovering ambulation after a traumatic spinal cord injury (tSCI) is a priority for patients and multiple CPRs have been proposed for predicting ambulation outcomes. Our objective is to confront clinical judgment to an established CPR developed for patients with tSCI. SETTINGS: Level one trauma center specialized in tSCI and its affiliated rehabilitation center. METHOD: In this retrospective comparative study, six physicians had to predict the ambulation outcome of 68 patients after a tSCI based on information from the acute hospitalization. Ambulation was also predicted according to the CPR of van Middendorp (CPR-vM). The success rate of the CPR-vM and clinicians to predict ambulation was compared using criteria of 5% for defining clinical significance, and a level of statistical significance of 0.05 for bilateral McNemar tests. RESULTS: There was no statistical difference between the overall performance of physicians (success rate of 79%) and of the CPR-vM (81%) for predicting ambulation. The differences between the CPR-vM and physicians varied clinically and significantly with the level of experience, clinical setting, and field of expertise. CONCLUSION: Confronting CPRs with the judgment of a group of clinicians should be an integral part of the design and validation of CPRs. Head-to-head comparison of CPRs with clinicians is also a cornerstone for defining the optimal strategy for translation into the clinical practice, and for defining which clinician and specific clinical context would benefit from using the CPR.

A Sensitive and Fast Fiber Bragg Grating-Based Investigation of the Biomechanical Dynamics of In Vitro Spinal Cord Injuries.

To better understand the real-time biomechanics of soft tissues under sudden mechanical loads such as traumatic spinal cord injury (SCI), it is important to improve in vitro models. During a traumatic SCI, the spinal cord suffers high-velocity compression. The evaluation of spinal canal occlusion with a sensor is required in order to investigate the degree of spinal compression and the fast biomechanical processes involved. Unfortunately, available techniques suffer with drawbacks such as the inability to measure transverse compression and impractically large response times. In this work, an optical pressure sensing scheme based on a fiber Bragg grating and a narrow-band filter was designed to detect and demonstrate the transverse compression inside a spinal cord surrogate in real-time. The response time of the proposed scheme was 20 microseconds; a five orders of magnitude enhancement over comparable schemes that depend on costly and slower optical spectral analyzers. We further showed that this improvement in speed comes with a negligible loss in sensitivity. This study is another step towards better understanding the complex biomechanics involved during a traumatic SCI, using a method capable of probing the related internal strains with high-spatiotemporal resolution.

Morphological features of thoracolumbar burst fractures associated with neurological outcome in thoracolumbar traumatic spinal cord injury.

PURPOSE: To identify specific morphological characteristics in thoracolumbar burst fractures associated with neurological outcome after severe traumatic spinal cord injury (TSCI). METHODS: We retrospectively analyzed the clinical and radiological (CT scan morphological characteristics) data of 25 consecutive patients admitted for TSCI secondary to a burst fracture at levels from T11 to L2 between 2010 and 2017 in single level-1 trauma center. We included severe TSCI, defined as American Spinal Injury Association Impairment Scale (AIS) grade A, B or C. RESULTS: Among the 25 patients with severe TSCI, 14 were AIS A, 5 were AIS B, and 6 were AIS C upon initial preoperative neurological evaluation. The AIS grade and the burden of associated injuries (Injury Severity Score, ISS) were the only clinical factors significantly associated with poor neurological recovery. The trauma level of energy was not associated with neurological outcome. Several fractures parameters were independently related to neurological recovery: the postero-inferior corner translation, presence of retropulsed fragment comminution and complete lamina fracture. The magnitude of sagittal kyphosis angle, vertebral kyphosis index and vertebral body comminution were not associated with the neurological outcome. CONCLUSIONS: Morphological features of the bony structures involving the spinal canal in thoracolumbar burst fractures with severe TSCI are associated with the chronic neurological outcome and could provide more insight than the AIS clinical grading. The fracture pattern may better reflect the actual level of energy transferred to the spinal cord than distinguishing between low- and high-energy trauma.

Patterns and predictors of functional recovery from the subacute to the chronic phase following a traumatic spinal cord injury: a prospective study.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To determine the extent of functional recovery between 6 and 12 months following a traumatic spinal cord injury (TSCI) and to identify individuals achieving a small clinical functional improvement during this period. SETTING: A single level-1 trauma center specialized in SCI care. METHODS: A cohort of 125 patients sustaining TSCI was studied. The Spinal Cord Independence Measure (SCIM) version III at 6 and 12 months post injury was used as the main outcome measure. RESULTS: The observed functional improvement for the final cohort did not reach a clinically significant level between 6 and 12 months post injury. However, 30.4% of individuals achieved this level (≥4 points in the SCIM-III total score). This group showed a higher proportion of motor-complete TSCI (AIS grade A or B) and showed a tendency toward older age and higher trauma severity. Longer duration of intensive functional rehabilitation was the single factor associated with reaching a small clinically important improvement in the SCIM-III total score. CONCLUSIONS: Functional status between 6 and 12 months following a TSCI may be considered clinically similar, regardless of the level of injury. However, 30% may reach a small clinical functional improvement in the subacute to chronic phase following TSCI, particularly individuals sustaining severe deficits and older age, which may highlight the importance of functional compensation during this period for these patients.

The use of classification and regression tree analysis to identify the optimal surgical timing for improving neurological outcomes following motor-complete thoracolumbar traumatic spinal cord injury.

STUDY DESIGN: Observational cohort study. OBJECTIVES: To identify the optimal surgical timing for improving neurological outcomes in patients that sustained a motor-complete traumatic spinal cord injury (TSCI) secondary to a thoracolumbar injury. SETTING: Level 1 trauma center specialized in TSCI care. METHODS: We prospectively analyzed clinical data of 35 patients admitted for motor-complete TSCI secondary to a thoracolumbar injury. We quantified neurological recovery with three different outcomes: the improvement of at least one grade on the American Spinal Injury Association Impairment Scale (AIS), of at least one neurological level of injury (NLI), and of at least 10-points on the motor score (MS). Classification and regression tree analysis was used to identify outcome predictors and to provide cutoff values of surgical timing associated with recovery. RESULTS: The proportion of the patients improving by at least one AIS grade was higher in the group undergoing early surgery within 25.7 h of the TSCI (46% vs 0%). The proportion of patients that improved by at least one NLI was also higher in the group undergoing early surgery within 21.5 h of the TSCI (71% vs 18%). Lastly, 25% of the AIS grade A patients undergoing early surgery within 25.6 h of the TSCI improved 10 MS points or more as compared with 0% in the other group. CONCLUSIONS: Earlier surgery was effective in improving neurological outcome in motor-complete TSCI at the thoracolumbar levels. Performing surgery within 21.5 h from the traumatic event in these patients increases the likelihood of improving the neurological recovery. SPONSORSHIP: This study was supported by the Fonds de Recherche du Québec-Santé (FRQS), Department of the Army-United States Army Medical Research Acquisition Activity, Rick Hansen Spinal Cord Injury Registry and Medtronic research chair in spinal trauma at Université de Montréal.

Defining criteria for optimal lumbar curve correction following the selective thoracic fusion surgery in Lenke 1 adolescent idiopathic scoliosis: developing a decision tree.

OBJECTIVE: The aim of this study was to identify the range of optimal versus suboptimal rates of spontaneous lumbar Cobb correction (SLCC%) and the factors predicting such outcomes in a cohort of Lenke 1 adolescent idiopathic scoliosis (AIS) after posterior spinal fusion surgery. METHODS: Seventy-one consecutive Lenke1 B and C AIS patients with a fusion level to L1 and higher with two-year follow-up were included. Thoracic kyphosis (T1-T4 and T4-T12 TK), lumbar lordosis (L1-S1 LL), thoracic and lumbar Cobb angles, thoracic and lumbar apical vertebral rotations and translations (AVR and AVT), pelvic incidence, sacral slope, and sagittal and frontal balances were measured at preoperative, early postoperative, and two-year follow-up. The SLCC% was calculated between preoperative and two-year follow-up. A clustering analysis determined the subgroups of patients with significantly higher and lower (optimal versus suboptimal) rate of SLCC% in the cohort at two-year follow-up. The cutoff values of the preoperative and early postoperative radiographic parameters that significantly predicted the optimal and suboptimal SLCC% were determined using a decision tree. RESULTS: The averages of the optimal versus suboptimal range of SLCC% in the cohort were 72% [55%, 105%] versus 39% [- 7%, 42%]. Preoperative and early postoperative spinal parameters predicted the optimal versus suboptimal SLCC% with an accuracy of 82%, 95%CI [0.73-0.94]. Preoperative AVTLumbar < 10 mm was a predictor of optimal SLCC%. In patients with a preoperative AVTLumbar > 10 mm, early postoperative T4-T12 TK < 24° (but not less than 17°) accompanied by - 5° < AVRThoracic < 5° were the main predictors of optimal SLCC% in our cohort. CONCLUSION: Quantitative clustering of the SLCC% into optimal and suboptimal groups allowed identifying the cutoff values of preoperative (AVTLumbar) and early postoperative (T4-T12 TK and AVRThoracic) spinal parameters that can predict the optimal range of SLCC% at two-year postoperative in our cohort of Lenke 1 AIS. LEVEL OF EVIDENCE: IV.

Traumatic Spinal Cord Injuries with Fractures in a Québec Level I Trauma Center.

BACKGROUND: Traumatic spinal cord injuries (TSCI) have devastating consequences on patients' quality of life. More specifically, TSCI with spinal fractures (TSCIF) have the most severe neurological impairment, although limited data are available. This study aimed at providing data and analyzing TSCIF in a level I trauma center in the province of Québec, Canada. METHODS: Two hundred eighty-two TSCIF were reviewed. Spinal injuries and neurological impairment were assessed with AO classification and AIS, respectively. Variables included age, sex, cause, location, mechanism of injury (MOI), and severity of TSCIF. Chi-squared Pearson determined significant associations (p < 0.05). RESULTS: Male-to-female ratio was 3.21:1. Patients were 42.5 ± 18.7 years. The leading causes of TSCIF were high-energy falls (28.4%), cars (26.2%) and vehicle without restraint system (motorcycle, all-terrain vehicle, snowmobile, and bicycle) (21.3%). Vehicle collisions, pooling cars and unrestrained vehicles, mostly affected the 20-49-year population (62.2%). The main MOI was distraction in males (47.9%), and axial compression in females (44.8%). There were significant associations between causes and injured spinal level, as well as between MOI and injured spinal level, sex, and TSCIF severity. Most patients involved in unrestrained vehicle accidents sustained a thoracolumbar spine distraction with complete motor deficit. A severe neurologic deficit affected most patients following car accidents that caused cervical spine distraction or axial torsion. CONCLUSIONS: In Québec, most TSCIF caused by vehicle collisions affect a young population and have severe neurological impairments. Future efforts should focus on better understanding accidents involving the unrestrained vehicle category to further improve preventive measures.

Des lésions traumatiques de la moelle épinière associées à des fractures dans le cadre d'un centre de traumatologie de niveau 1 du Québec Contexte: Les lésions traumatiques de la moelle épinière (LTME) ont des conséquences catastrophiques sur la qualité de vie des patients qui en sont victimes. De façon plus particulière, il faut savoir que les LTME associées à des fractures vertébrales sont celles qui entraînent, bien que les données à ce sujet soient limitées, les déficiences neurologiques les plus graves. Cette étude vise à collecter des données et à analyser les LTME associées à des fractures vertébrales dans un centre de traumatologie de niveau 1 situé au Québec (Canada). Méthodes: Au total, nous avons examiné 282 cas de LTME associés à des fractures vertébrales. Pour ce faire, nous avons évalué ces fractures au moyen de la classification Müller AO ; quant au niveau de déficience neurologique, nous l'avons évalué au moyen de l'échelle ASIA. Parmi les variables incluses dans cette étude, mentionnons l'âge, le sexe, la cause, l'endroit de l'incident, le mécanisme de blessure (mechanism of injury) ainsi que la gravité des LMTE associées à des fractures vertébrales. Enfin, c'est au moyen du test du X2 de Pearson qu'on a pu déterminer des associations statistiques valables (p < 0,05). Résultats: Le rapport hommes/femmes était de 3,2 :1. En moyenne, les patients étaient âgés de 42,5 ans ± 18,7 ans. Les principales causes de LMTE associées à des fractures vertébrales se sont révélées être des chutes à haut transfert d'énergie (28,4 %), des accidents de la route impliquant des automobiles (26,2 %) et des accidents impliquant des moyens de transport (motocyclettes, VTT, motoneiges et vélos) dépourvus d'un dispositif de retenue (21,3 %). Tant les collisions à bord d'une automobile que celles impliquant un moyen de transport sans dispositif de retenue ont surtout affecté la population des 20 à 49 ans (62,2 %). Chez les hommes, le principal mécanisme de blessure était la distraction de la colonne (47,9%) alors que chez la femme, c'était la compression axiale (44,8%). Des associations significatives sont apparues entre les causes énumérées ci-dessus et la gravité des blessures à la colonne vertébrale de même qu'entre le mécanisme de blessure et la gravité des blessures à la colonne vertébrale, le sexe des patients et la gravité des LMTE associées à des fractures vertébrales. La plupart des patients victimes d'un accident sur un véhicule sans dispositif de retenue ont subi une distraction thoraco-lombaire de la colonne vertébrale jumelée à un déficit moteur complet. Enfin, un déficit neurologique marqué a affecté la plupart des patients victimes d'un accident de la route ayant subi une distraction cervicale et une torsion axiale. Conclusions: Au Québec, la plupart des LMTE associées à des fractures vertébrales et causées par des accidents de la route affectent une population plus jeune et entraînent de graves déficits neurologiques. À l'avenir, on devrait tenter de mieux comprendre les accidents impliquant des moyens de transport dépourvus de dispositif de retenue afin d'améliorer davantage les mesures préventives.

Long-term follow-up after surgical treatment of adolescent idiopathic scoliosis using high-density pedicle screw constructs: Is 5-year routine visit required?

PURPOSE: The objective of this study is to determine whether routine follow-up 5 years after adolescent idiopathic scoliosis (AIS) surgery is likely to affect postoperative care for patients treated with high-density pedicle screw constructs, when routine 2-year follow-up has been performed. METHODS: We reviewed 80 patients undergoing surgery for AIS using high-density pedicle screw constructs and followed routinely 2 and 5 years after surgery. Quality of life (QOL) was assessed using the SRS-30 outcome questionnaire. Reoperations occurring between 2 and 5 years after surgery were identified. RESULTS: Curve correction and QOL were similar between 2- and 5-year visits. Two patients required revision surgery after presenting during unplanned visits between the 2- and 5-year follow-ups. One patient presented at the routine 5-year visit with an asymptomatic undisplaced rod fracture without loss of correction, and it was decided to follow-up only as needed. CONCLUSIONS: In AIS patients for whom routine follow-up 2 years after surgery using high-density pedicle screw constructs was uneventful, additional routine 5-year follow-up is not likely to affect postoperative care and revision rate. Patients developing complications and needing reoperation between 2 and 5 years after surgery will most likely present during unplanned visits rather than during routine follow-up appointments. Easy access to emergent visits on an as-needed basis is therefore important for this population if routine 5-year follow-up is not planned. These slides can be retrieved under Electronic Supplementary Material.

Criteria for surgical reduction in high-grade lumbosacral spondylolisthesis based on quality of life measures.

PURPOSE: Although surgical reduction in high-grade lumbosacral spondylolisthesis is often performed in young patients, criteria for defining adequate reduction leading to optimal outcomes have yet to be defined. The purpose of this study is to determine if surgical reduction in pelvic balance, slip grade, lumbosacral angle and L5 incidence are associated with quality of life after surgery, based on specific criteria proposed previously in the literature. METHODS: A prospective cohort of 61 patients (14.4 ± 2.7 years) with high-grade lumbosacral spondylolisthesis was followed for a minimum of 2 years after surgery. SRS-22 scores, slip grade, lumbosacral angle, pelvic balance and L5 incidence were assessed before surgery and at the latest follow-up. Multivariable regression analyses were performed using postoperative SRS domain and total scores as the dependent variables. Independent variables consisted of the preoperative SRS scores, and specific criteria of pelvic balance, slip grade, lumbosacral angle and L5 incidence. The influence of slip grade, lumbosacral angle and L5 incidence on pelvic balance was also assessed. RESULTS: Obtaining a balanced pelvis postoperatively was mainly predictive of improved satisfaction with surgery and self-image and also tended to be associated with higher scores for other domains. Improved mental health was associated with reduction to a low-grade slip. Reduction in lumbosacral angle was not predictive of quality of life. Postoperative pelvic balance was mainly associated with preoperative pelvic balance, but there was a tendency for achieving normal pelvic balance when the postoperative L5 incidence was 60° or smaller. CONCLUSIONS: When performing surgery in young patients with high-grade lumbosacral spondylolisthesis, achieving normal pelvic balance is the key because it is associated with improved quality of life. Reduction to a low-grade slip is predictive of improved mental health, but reduction in lumbosacral angle is not associated with postoperative quality of life. There was a tendency for obtaining normal postoperative balance in patients with postoperative L5 incidence 60° or smaller. These slides can be retrieved under Electronic Supplementary Material.

Predicting lowest hemoglobin level and risk of blood transfusion in spinal fusion surgery for adolescent idiopathic scoliosis.

PURPOSE: The aim of this study was to evaluate the factors associated with timing of lowest hemoglobin (Hb) level and the need for postoperative blood transfusion in posterior spinal fusion for adolescent idiopathic scoliosis. METHODS: We conducted a retrospective review of all adolescent scoliosis patients undergoing posterior spinal fusion at our institution, 2002-2014. Surgery consisted of segmental pedicle screw fixation using multi-level pedicle screws. Blood-saving techniques were used in all patients. Data included Cobb angle, pre- and postoperative Hb levels, preoperative autologous blood donation (PABD), surgery duration, and allogeneic or autologous transfusion. We used linear and logistic regressions for statistical analysis. RESULTS: There were 456 patients (402 female, 54 male), mean age 16 ± 5 years. Lowest Hb was observed on postoperative Days 2 (32.2%) and 3 (33.3%); 45.1% of postoperative transfusions occurred on Day 2. One hundred and eighty-eight (41%) patients who provided PABD had significantly lower preoperative Hb and received more transfusions intraoperatively (22.6% vs. 5.2%) and postoperatively (20% vs. 6.3%) than others. Probability of transfusion increased 49.6 (95% CI 17.40-141.37) times with preoperative Hb < 11 g/dL as compared to preoperative Hb > 14 g/dL. Probability of transfusion increased 4.3- and 9.8-fold when surgery duration exceeded 5 and 6 h, respectively. Probability of transfusion increased 3.3- and 5.3-fold with Cobb angle > 70° and 80°, respectively. CONCLUSIONS: We identified clear patient-specific perioperative parameters that affect risk of perioperative blood transfusion, including Cobb angle, PABD and preoperative Hb. Hb measurement beyond postoperative Day 3 is considered unnecessary unless clinically indicated. These slides can be retrieved under Electronic Supplementary Material.