Complete Neurological Deficit Research Articles

Traumatic lateral spondyloptosis and lateraloptosis with partial improvement through posterior surgical approach: a review based on a case report

Introduction. Spondyloptosis or grade V of spondylolisthesis, spinal injury that involve 100 % mobilization of the vertebral body, is rare to find. Lateraloptosis, displacement of vertebral bodies, is even more rare a catastrophic.The aim of this study to introduce readers to this rare form of traumatic lumbar spine injury as well as to review current available therapeutic approaches.Case report. A 22-year-old male was admitted to the emergency room due to a fall from a moving truck. Physical examination revealed neurological deficit in the lower extremities, with muscle strength 0/5, and an ASIA B classification. Computed tomography study showed a complete lateroloptosis at the L3 –L4 level. The patient is admitted to the operating room for surgical treatment through a posterior approach. Successful arthrodesis and spinal alignment are achieved. Immediate postoperative period, showed no complications and the patient’s neurological function in the lower extremities was classified as ASIA C. In the posterior follow-up, the patient maintains the motor neurological function and recover the autonomic control of bladder function. With mild disability according to the Barthel Index of 90 points.Discussion. of the traumatic spinal injuries, spondyloptosis is the most infrequent and occurs secondary to high-energy mechanisms. It presents an incidence of complete neurological deficit in 80 % of patients. The objectives in surgical treatment are decompression of neurovascular structures, reduction of fracture dislocation to improve alignment in the sagittal and coronal plane, and instrumentation that allows stability. The posterior surgical approach offers advantages over the anterior approach. In the posterior approach, the facet joints can be manipulated more safely, decompress the nerve roots and the dural sac more easily, as well as less operating time and greater care of vascular structures such as the iliac vessels.Conclusion. Complex traumatic spinal injuries are associated with irreversible neurological damage. Achieving spinal stability and alignment allows optimizing physical therapy and rehabilitation for greater recovery. Severe spinal injuries, especially lateroptosis, are difficult to treat by surgical approach, however, the main objective is vertebral stabilization to allow physical therapy and early rehabilitation.

Missile Injuries to The Spine Local Experience and Review of The Literature

Introduction: Missile injuries of the spine particularly the high velocity projectiles are very destructive, leading to real disaster and even death. The incidence has increased recently on both civilian and military troops. The ideas behind writing this article is to shed the light on the seriousness of this type of injury and on the consensus for the ideal treatment depending on our local experience and others experience. Materials and Methods: We review our patient’s files whom had missile injuries related to orthopaedic practice since the last 40 years in public and private hospitals and we also search the web looking for articles discussing missile injuries in orthopaedic practice. We collect complications that observed in our patients and reported in literatures to be mentioned in the results of this review. Results: Missile injuries is the cause of 13-44% of all spinal injury. The cervical lesion is behind complete neurological deficit in 70% of cases. Almost all injuries are stable particularly in the cervical lesion provided that both facet and both pedicles remain intact. Probably pain is one of the commonest complications recorded. Bullets removed did not relieve the pain due to depression. Infection is very much expected after the dirty missile wounds. Neurogenic bladder and urinary tract infection are also possible, meningitis, bone infection, Charcot arthropathy and deformity are all possible. Lead intoxication is a late and very rare complication. The last rare but possible complication is the migration of the missile. Conclusions: Gunshot injury to the spine is becoming more and more prevalent in both military and civilian practice. Probably the absolute indication for surgery is the progressive neurological deficit. A cover of antibiotic is mandatory. A careful search for the instability is mandatory and lastly, Steroids use in spinal missile injuries is controversial.

Prevalence, Implications, and Risk Factors of Traumatic Dural Tears in Thoracic and Lumbar Fractures: A Retrospective Study.

Introduction Spine fracture in association with traumatic dural tear is a serious injury. A traumatic dural tear is difficult to determine based on initial clinical presentation and radiological imaging even with magnetic resonance imaging (MRI). However, during decompression surgery, cerebrospinal fluid leaks surrounding the injured segments are usually confirmed by directly visualizing them. For preoperative planning and intraoperatively limiting further damage to the dural and neurological structures, early detection of traumatic dural tears before surgery is important. This study aims to determine the prevalence, implication, risk factors, and complications of traumatic dural tears in patients who have undergone surgical treatment for thoracic and lumbar fractures. We believe our retrospective study would identify more accurate risk factors for traumatic dural tears and aid us with preoperative planning and operative precaution. Methods This study retrospectively included all patients who had thoracic and lumbar fractures and had posterior instrumentation and decompression surgery at three hospitals in the Northern region of Malaysia from January 2018 to December 2020. Fractures associated with pathological spine including metastatic, severe osteoporosis, ankylosing spondylitis, metabolic bone disease, those with missing data, and iatrogenic dural tears were excluded from this study. Preoperative and postoperative neurological assessments based on theAmerican Spinal Injury Association (ASIA) impairment scale, blood loss volume, duration of the surgery, and post-surgery complications were gathered from medical records. Interpedicular distance, ratio of central canal diameter, laminar fracture gap, and pedicle fractures were identified and measured. The obtained data was analyzed using Pearson's chi-square and Fisher's exact test for categorical variables, and independent t-test/Mann-Whitney test for numerical variables. Result This study comprised a total of 93 patients who had fractures in their thoracic and lumbar regions. The mean age of the patients was 38 years. The number of patients with traumatic dural tears was 20 (21.5%). There was an association between the presence of dural tears and preoperative neurological deficits (P<0.001). Wider mean interpedicular distance (P=0.004), increased central canal diameter ratio (P<0.001), and displaced laminar fracture (P<0.001) were significantly higher in patients with traumatic dural tears. Multiple logistic regression analysis showed both incomplete (P=0.002) and complete (P=0.037) preoperative neurological deficit, increase of central diameter ratio of encroachment (P=0.011), and presence of >2mm laminar fracture gap (P=0.015) had a significant association with a traumatic dural tear. This study found that patients with traumatic dural tears had longer surgical times and statistically larger mean blood loss volumes when compared to patients without dural tears (P<0.001). There is no significant association between the complications following the surgery and the presence of a dural tear (P>0.05). Conclusion This study shows that the presence of preoperative neurological deficits, wider interpedicular distance, severe canal encroachment, and wide separation of laminar fracture may indicate the likelihood of traumatic dural tear in spine fracture. These factors will enable surgeons to enhance their operational planning and make early preparations for the management of dural tears.

Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures

BackgroundThere is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.Materials and methodsThe Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment.ResultsConsensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is “as early as possible”. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated.ConclusionsThis consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients.Level of Evidence: IV.Trial registration: not applicable (consensus paper).

Risk factors for thirty-day morbidity and mortality after spinal trauma.

Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined. Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed. The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87days. Cervical spine injury (p < 0.0001), delay in surgery > 48h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay. Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

Risk Factors for Postoperative Complications and In-Hospital Mortality Following Surgery for Cervical Spinal Cord Injury.

Background and objective The operative priority in the setting of traumatic cervical spinal cord injury (SCI) is to decompress the injured spinal cord and stabilize the vertebral column. Currently, there is a relative paucity of evidence regarding associations of patient and surgical factors with in-hospital mortality following traumatic SCI. In light of this, the aim of this study was to investigate the correlation of injury, patient, and surgical factors with in-hospital morbidity and mortality. Methods The study was designed as a retrospective cohort study. The electronic medical records (EMR) at a single tertiary centre in Australia were retrospectively reviewed over a five-year period (2016-2021). All adults who were admitted to undergoemergency surgery for cervical SCI were identified and reviewed for patient factors (age, sex, comorbidities), injury factors [injury severity score (ISS), American Spinal Cord Injury Association (ASIA) classification], and surgical factors (anterior/posterior/360 instrumentation, greater than five levels instrumented, operative time). Factors were correlated to in-hospital complications (infection, pressure injury, ventilator dependency, venous thromboembolism, stroke) and in-hospital mortality by using univariate analysis and multivariable logistic regression models. Results A total of 92 patients were identified from the EMR. The median patient age was 54.5years [interquartile range (IQR): 2.5];77(82.2%) of the participants were male. The median ASIA classification was C4 ASIA C. In-hospital mortality following surgery was 6.5% (n=6). Of these patients, the primary cause of death was respiratory failure in 83.3% (n=5). In-hospital mortality was associated with anticoagulation (p=0.01), coronary disease (p=0.012), complete injury (p=0.011), and ventilator dependency (p<0.001). Postoperative pneumonia was associated with complete injury (p=0.009) and polytrauma (p=0.002). Ventilator dependency was associated with complete injuries (p<0.001) and polytrauma (p<0.001). A logistic regression analysis found complete neurological injury to be significant in predicting in-hospital mortality [odds ratio (OR): 184.53, 95% confidence interval (CI): 2.41-14106.65, p=0.018, R2=0.58]. Conclusion To improve surgical outcomes in patients with traumatic cervical SCI, a concerted effort must be made to prevent postoperative complications. Cardiovascular comorbidities present significant risk factors for patients. Patient age appears to insignificantly influence postoperative complication rates; however, this finding may have been influenced by selection bias. Postoperative respiratory complications, especially in patients with complete neurological deficits, can be particularly devastating.

Retained Metallic Part of a Dislodged Knife in the Thoracic Spine with Paraparesis

The incidence of traumatic spinal cord injury is reported as 30-40 million per year. Among these, stab wounds to the spinal canal are usually rare. These injuries often lead to complete or incomplete neurological deficits. An appropriate management can ensure good functional recovery for approximately two-third of the patient. As these cases are uncommon, their treatment protocols are still controversial and under evaluation. Some literatures reveal various surgical approaches. Spinal canal injury with retained part of the causative agent (knife, bullet, glass etc.) or any other complication on the wound site demands immediate surgical exploration. Here we report on a patient with a retained metallic foreign body (tip of knife) in the thoracic region traversing the left pedicle of sixth thoracic vertebrae along with spinal canal with paraparesis and after neuro-surgical exploration and complete removal of the foreign body, patient shows gradual improvement of neuro-functional status. Proper wound care and long term close follow up was ensured during post operative period.

Morcellized local grafts as cost effective option for interbody fusion in thoracolumbar fracture dislocation: Seven years follow up of 53 patients

IntroductionTraumatic fracture dislocation of the spine injury is essentially a three column injury that optimally needs surgical intervention to decompress, stabilize and fuse the spinal column. This study evaluate the outcome of posterior and posterolateral decompression, instrumentation and 360 degree fusion achieved with help of locally harvested autologus morcellized grafts in traumatic fracture dislocation of thoracolumbar spine. Methods53 patients were included in this retrospective study. Patients aged 16-55 years, single level fracture dislocation of thoraco-lumbar spine (D5-L5) were included. Patients with multiple level fractures, coexisting degenerative diseases of spine ,pathological fractures, patients presenting more than three weeks after initial trauma, patients with concomitant severe head injury that necessitated emergency surgery for the same were excluded from the study. Patients underwent posterior and posterolateral decompression , posterior instrumentation and interbody as well as posterolateral fusion with use of morcellized bone from resected posterior elements. Follow up data at immediate post operative period ,12 months and yearly thereafter upto minimum 7 years was obtained from previous record. ResultsThere were 46 males and 7 females. Mean age was 31.15 ±9.64 yrs .Mean follow up period was 7.4 yrs(range 7-10 yrs). Thoracolumbar dislocation was most frequently noted at thoraco lumbar junction (T10-L2).Thirty six patients had complete neurological deficit (ASIA A) and sixteen had incomplete neurology. At one year follow up, osseous fusion was noted in 48 (90.56%) patients and 5 patients (9.44%) had fibrous union which was determined on CT scan. Immediete post operative, one year and 7 year kyphosis angle was calculated and change in kyphosis angle was not statistically significant. There was no implant failure till last follow up. ConclusionMorcellized locally harvested autologus grafts are sufficient to achieve 360 0 spinal fusion in fracture dislocation of thoracolumbar spine.

Accuracy of MRI (TLICS vs AOSIS) in assessment of thoracolumbar spine injuries for guiding treatment

BackgroundThe thoracic segment represents the most common area fractured in the whole spine. Complete neurological deficits are commonly associated with thoracic injuries possibly due to a relatively small canal diameter as compared to the cervical or lumbar spine. Magnetic resonance is the gold standard of imaging, especially in patients suffering from neurological deficits as well as in soft tissue assessment mainly the disc, ligaments, and neural elements. The thoracolumbar injury classification and severity score system (TLICS) and the thoracolumbar AO Spine injury score (TLAOSIS), are two scoring systems designed to help surgeons in management plans of thoraco-lumbar injuries. The aim of our study is to compare these two main thoracolumbar injury classification systems in deciding the management strategies in thoraco-lumbar injuries. This study is a retrospective study that included 70 patients (42 males and 28 females) who suffered acute traumatic vertebral fractures. All patients underwent MRI including T1WI, T2W and STIR sequences. The MRI was viewed by two independent radiologists of 5- and 10-years’ experience and compared to surgical decisions.ResultsOut of 70 patients included in our study, the TL AOSIS matched treatment recommendation in 62 patients (88.6%), and the TLICS matched in 60 patients (85.7%). The TL AOSIS achieved sensitivity 95%, specificity 80%, while the TLICS achieved sensitivity 72.2%, specificity 100%.ConclusionBoth TL AOSIS and TLICS have very close results in their reliability for guiding treatment strategy, yet TL AOSIS matched treatment recommendation more than TLICS, with sensitivity more than TLICS, while TLICS had more specificity.

Pattern of spine fracture in Sub-Himalayan region: A prospective study

BackgroundThough spine trauma contributes to great functional, psychological, and economic loss, research regarding the demographic profile of patients according to different regions of our country are lacking.This study aims to identify the demographic pattern and clinical profile of patients with spinal fracture in the Sub-Himalayan region. MethodPatients with acute or subacute spine trauma presenting within 8weeks and involving fracture of cervical, dorsal, or lumbar vertebra, from July 2017 to December 2019 were included prospectively. Patients with osteoporotic or metastatic collapse, isolated transverse or spinous process fracture, penetrating trauma or ballistic injuries were excluded. ResultsOut of 280 enrolled patients, 180 were males and 100 were females. The maximum number of spine trauma patients was in 16–30 years age group. The most common mechanism of injury was fall from height (FFH, 42.5%)> road traffic accident (RTA, 38.6%). RTA was more common among males and FFH among females (p < 0.0001). Most common location of injury was at thoracolumbar junction (D10-L2) (37.5%) followed by cervical spine (25.3%). 58.2% of patients had AO type A facture morphology followed by AO types C (36.1%) and AO type B (5.7%). Spinal Cord Injury (SCI) was seen in 82.1% spine trauma patients with statistically significant association with male gender (p- 0.045). Complete paralysis was seen maximum in patients with cervical spine injury (67.3%, p < 0.0001). Complete neurological deficit (ASIA grade A) was seen maximum in AO type C fracture morphology (74.25%, p < 0.001) followed by AO type A4 (29.6%). Seasonal distribution showed increased incidence during summer and monsoon season. ConclusionYoung aged males in age group of 16–30 yrs were most commonly affected with fall from height as the most common mechanism of trauma. Association was found between gender and mechanism of injury (RTA in males and FFH in females). Most common vertebral injury level was thoracolumbar junction. AO type A was the most common fracture morphology. SCI seen in 82.1% of spine trauma. Statistically significant association was found between Complete SCI with Location of Injury (Cervical) and Fracture morphology (AO type C).

Reliability and Validity of the English Version of the AOSpine PROST (Patient Reported Outcome Spine Trauma).

Multicenter validation study. The aim of this study was to translate and adapt the AOSpine PROST (Patient Reported Outcome Spine Trauma) into English, and test its psychometric properties among North-American spine trauma patients. In the absence of an outcome instrument specifically designed and validated for traumatic spinal column injury patients, it is difficult to measure the effect size of various treatment options. The AOSpine Knowledge Forum Trauma initiated a project and developed the AOSpine PROST consisting of 19 items. Patients were recruited from two level-1 North-American trauma centers. For concurrent validity, next to AOSpine PROST also 36-item Short-Form Health Survey (SF-36) was filled out by patients. Patient characteristics were analyzed using descriptive statistics. Floor and ceiling effects as well as the number of inapplicable and missing questions were analyzed for content validity. Cronbach α and item-total correlation coefficients (ITCCs) were calculated for internal consistency. Spearman correlation tests were performed within AOSpine PROST items and in correlation to SF-36. Test-retest reliability was assessed using intraclass correlation coefficients (ICCs). Factor analysis was performed to explore any dimensions within AOSpine PROST. The AOSpine PROST was translated adapted into English using established guidelines. Of 196 enrolled patients, 162 (82.7%) met the inclusion criteria and provided sufficient data. Content validity showed good results, and no floor and ceiling effects were seen. The internal consistency was excellent (Cronbach α = 0.97; ITCC 0.50-0.90) as well as test-retest reliability (ICC = 0.97). Spearman correlations were good (0.29-0.85). The strongest correlations of AOSpine PROST with SF-36 were seen with the physical components (0.69-0.82; P < 0.001). Factor analysis revealed two possible dimensions (Eigen values >1), explaining 75.7% of variance. The English version of AOSpine PROST showed very good validity and reliability. It is considered as a valuable tool, and has the potential to contribute to the reduction of ongoing controversies in spine trauma care. 2.

Short-Segment Fixation of Thoracolumbar Fractures with Incorporated Screws at the Level of Fracture.

ObjectiveTo evaluate the effect of including the fractured vertebra in the short‐segment fixation of thoracolumbar (TL) fractures.MethodsA total of 32 patients with thoraco‐lumbar fractures, selected between August 2013 and February 2016, were managed by short‐segment fixation with screws at the level of the fracture, and decompression was performed only for patients with neurological deficits. The patients' functional outcome was assessed using the visual analogue scale (VAS) score for pain and the American Spinal Injury Association (ASIA) score for neurological condition. All patients were followed up with radiographs.ResultsPatients with complete neurologic deficits (n = 3) did not show any neurologic recovery. All ASIA B patients improved to ASIA C. Five ASIA C patients improved to ASIA E. The remaining five ASIA C patients improved to ASIA D. All ASIA D patients improved to ASIA B. At the final follow‐up examination, the mean anterior vertebral height was 21 ± 5 mm, indicating no significant height loss during the follow‐up period.ConclusionShort‐segment fixation of TL fractures with inclusion of the fracture level into the construct offers good correction of segmental kyphosis, vertebral wedging, and vertebral height loss.

Compliance with prescriptions for wheelchairs, walking aids, orthotics, and pressure-relieving devices in patients with traumatic spinal cord injury.

The use of adaptive equipment (AE) is the basic indication for patients with spinal cord injury (SCI). Inappropriate decisions concerning the use of AE imply treatment results, patient confidence, and patient and state costs. The present study is the first analysis of the causes of non-compliance conducted in Europe with the provision of AE in SCI patients using Wielandt and Strong's classification. The aim of this study is to analyze of the causes of non-compliance in the process of providing AE to SCI patients. Retrospective observational study. "STOCER" Masovian Rehabilitation Centre, Konstancin-Jeziorna, Poland. Seventy-two patients with traumatic SCI 10 months after the completion of the acute and post-acute phases of inpatient rehabilitation. Wielandt and Strong's classification was used to determine the causes of non-compliance with AE provisions and the present authors' questionnaire with the World Health Organisation Quality of Life (WHOQOL-BREF) were used to identify the risk factors of non-compliance with AE provisions. Non-compliance with prescribed AE provisions was reported in 34 (49.3%) of 69 study participants. Non-compliance was due to medical-related factors in 44.1%, client-related factors in 20.6%, equipment-related factors in 11.8%, and unspecific factors in 17.8% of cases. Non-compliance with AE provisions correlated with complete neurological deficit, preserved ability to walk (in case of wheelchairs), the presence of bedsores (in cases of lower extremity devices), low financial status, and lost ability to walk (in cases of AE for standing and walking). The highest percentage of non-compliance was noted for the provision of knee-ankle-foot orthosis (50%). The most common causes of non-compliance with AE provisions include health status improvement in the patient and high cost of the device. These results can be helpful for more effective treatment planning and the avoidance of unnecessary reimbursement costs covered by the state and users.

Prognostic utility of magnetic resonance imaging (MRI) in predicting neurological outcomes in patients with acute thoracolumbar spinal cord injury.

Utility of MRI for predicting neurological outcomes in acute cervical spinal cord injury (SCI) is well established but its value in thoracolumbar (TL) SCI needs to be evaluated. Seventy-six patients operated for acute TL spinal injuries between January 2014 and March 2016 were reviewed to obtain demographic details, neurology at admission and at the final follow-up. Patients were divided based on the neurology at presentation into group 1 (ASIA A), group 2 (ASIA B, C, D) and group 3 (normal neurology). Preoperative MRI and CT scans were evaluated to measure parameters like osseus canal compromise, spinal cord compression (SCC), spinal cord swelling, length of cord swelling (LOS), length of edema (LOE) and the presence of hemorrhage. The MRI parameters were compared between the groups for their predictive value of neurology on admission and at the final follow-up. Of the 38 patients in group 1, six patients recovered by 1 grade, nine patients recovered by 2 grades and there was no recovery in 23 (60.5%) patients. Among group 2 patients, nine (40.9%) out of 22 recovered to ASIA E neurology. On univariate analysis, SCC (P = 0.009), LOS (P = 0.021) and length of edema (P = 0.002) were associated with complete neurological deficit at presentation. However, on multivariate regression analysis only LOE was significant (P = 0.007) in predicting neurology at admission and at follow-up. Greater the rostrocaudal LOE, worse is the neurology at presentation, and it is associated with poor neurological recovery at follow-up. These slides can be retrieved under Electronic Supplementary Material.

Outcome of fractures of dorso lumbar spine treated by short segment posterior stabilization with intermediate pedicle screws

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Spine fractures are common in today’s world due to high frequency of motor vehicle accidents and work place injuries. These are major cause of disability in adult population. The mortality rate following spinal injuries is 7%. The aim of the study was to study the functional and radiological outcome of fractures of dorso lumbar spine treated by short segment posterior stabilization with intermediate pedicle screws.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Dorso-lumbar fractures with intact pedicle on the fractured segment, Load sharing classification score of equal or less than 6, Neurologic involvement caused by the fracture, loss of vertebral body height by more than 50% and kyphosis angle more than 20° are included. Patients with multiple level fractures and pathological fractures were excluded from the study. Denis classification and AO classification were used. Load sharing score is used to decision making for intermediate screw fixation.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; L1 is more frequently fractured followed by D12. Distraction type (AO) and burst (Denis) are most common types. 4 of our patients had complete neurological deficit. 15 had incomplete deficit and 11 patients doesn’t have any neurological involvement. Frankel A grade cases remained in the same grade. Mean Kyphotic correction is 6.7°. Mean AVBCP in the postoperative cases 26. None of the cases developed kyphosis or loss of correction in the follow up. Outcome using Roland Morris disability questionnaire is excellent in 64.3%, good in 21.6% and poor in 14.3% cases.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; To conclude that short segment posterior stabilisation with intermediate screws provides better biomechanical stability when compared with conventional short segment fixation.&lt;/p&gt;

Review of Subaxial Cervical Spine Injuries Presenting to a Tertiary-Level Hospital in Nepal: Challenges in Surgical Management in a Third World Scenario.

Study Design:Epidemiological retrospective study.Objective:To describe the demographics, timing to surgery, delay, short-term neurological recovery, and complications in surgically treated subaxial cervical trauma in a resource-constrained country.Methods:Thirty consecutive subaxial cervical trauma patients presenting to a trauma hospital in Nepal between December 2015 and August 2017 were analyzed as a retrospective cohort. Patients were segregated into 4 groups based on the timing to surgery: within 2 days, 3 to 7 days, 8 to 30 days, and >31 days.Results:There were 27 male and 3 female patients with mean age 40 years. Twenty-four sustained fall injury, and 27 patients were from outside Kathmandu. No patients were treated within the first 48 hours; only 9 were treated between 3 and 7 days, 16 between 8 and 30 days, and 5 a month later. Major delay was finance and operating room availability. Thirteen patients had a C6C7 involvement followed by C5C6 in 6 patients. Seven patients had complete neurological deficit while 18 patients had incomplete deficit. A total of 46.7% improved their neurology in 6 months. No neurological recovery was observed in complete deficit patients.Conclusion:Seventy percent of our patients were treated longer than 1 week after injury, which would likely be considered unacceptable in most first world countries. As expected, the outcomes for many of these patients were far worse than reported in North American centers with early access to medical care and insurance. Despite this, nearly half of our patients improved neurologically following treatment; hence, surgery holds hope of some restoration of neurologic deficits.

Anterior reconstruction of spine by posterior approach in cases of unstable thoracolumbar burst fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The purpose of this study is to evaluate neurological, functional and radiological outcome of the anterior reconstruction of spine by posterior approach in cases of unstable thoracolumbar burst fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Ten patients with acute unstable burst fractures at thoracolumbar junction (T-11 to L-3) with partial or complete neurological deficit in the age group of 18-50 years with McCormack’s score six or more and thoracolumbar injury severity score (TLISS) five or more were included. Neurological status, Japanese Orthopaedic association score (JOA score), visual analogue scale (VAS), angle of kyphotic deformity, McCormack’s score and TLISS score were evaluated.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The mean duration of surgery was 282 minutes. The mean blood loss was 1885 ml. Five patients with neurologic deficit recovered an average of 1.40 ASIA grades at last 24 months’ follow-up. The JOA score improved from -6 preoperatively to 11 at 24 months follow up. The mean kyphotic angle was 19 degrees preoperative improved to -0.6&lt;sup&gt;o&lt;/sup&gt; postoperatively. Visual analogue score improved from 6.1 to 1.7.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The familiar posterior approach is a safe and reliable surgical approach for reconstruction of all the columns of spine. It has the advantage of doing anterior decompression and reconstruction with posterior instrumentation in single stage, reducing the operative time and blood loss. It reduces the morbidity of anterior approach (isolated or two staged) in the hands of an average orthopaedic surgeon.&lt;/p&gt;

A study on functional outcome following surgical fixation for subaxial cervical spine injuries

Background: Cervical instability due to trauma is usually from level c3 to c7 (i.e sub axial). Neurological deficit are common i.e root compression and cord compression with subluxation and dislocation. Unstable cervical spine injuries with or without neurological deficit require open reduction. Stabilization is done by using various implants and bone grafting. Implants provide immediate stability, whereas bone grafts provide long term stability by achieving intervertebral fusion. Hence to relive from the primary impact, persistent compression and alignment of stable anatomy of cervical spine, early surgical intervention is necessary to relieve persistent compression and stabilization of subaxial cervical spine injuries. Aim of the study: To study the functional outcome following surgical fixation for subaxial cervical spine injuries involving patients who all are admitted with subaxial cervical spine injuries & amenable to intervention in our department of orthopaedics & traumatology, govt rajaji hospital, madurai from September 2011 to September 2015 Results: All the cases are male with most of the patients are in the age group of 41-50 years, Fall from height is the most common of injury followed by road traffic accident, C5-C6 # dislocation is most common spinal injury pattern. Incomplete neurological deficit are more in this study. Most of the cases are flexion distraction type of violence. Most of the cases presented with in one week of injury. Only 4 cases of 40 cases operated by global fusion, both of them are presented late and found to have locked facets. 4 out of 6 cases are expired from complete neurological deficit. Mobilisation of neck started after 6 weeks. Totally 6 cases were expired. Two cases was due to acute respiratory distress syndrome. One case due to aspiration pneumonia is. Four patients developed bed sores in which one case developed bed sore preoperatively and other postoperative lay. One patient who had grade 6 sacral sore underwent flap cover with the help of plastic surgeon intervention. Other 6 patients managed conservatively. Conclusion: The ultimate goal of surgical intervention for subaxial cervical spine injuries is stabilization of spine, restoration of spinal anatomy, decompression of neural elements, thereby promoting the neurological recovery and early facilitation of rehabilitation. In our study, we achieved a good functional outcome following surgical intervention. To conclude that early surgical stabilization of subaxial cervical spine injuries has good functional outcome, provided detailed clinical and radiological assessment, proper preoperative planning, selection of surgical approaches, precision in surgical techniques and early rehabilitation program are needed in achieving good results and minimising complications.

ATYPICAL SEGMENTAL CORRECTIVE VERTEBRECTOMY IN THE TREATMENT OF POST-TRAUMATIC THORACIC KYPHOSIS

Objective. To analyze results of atypical segmental corrective vertebrectomy in patients with painful thoracic kyphosis treated in the late period of spinal cord injury. Material and Methods. Eight patients with painful kyphotic and shear deformities were operated on during 2012. The method of atypical segmental corrective vertebrectomy was used. Average kyphotic deformity was 43.1° ± 15.0°, the rate of anterior shear displacement varied from 25 to 48 %. Results. The average kyphosis correction was 9.1° ± 5.8° with complete correction of shear deformity. Questionnaire data showed the decrease in pain score from 4.4 ± 1.8 to 2.6 ± 1.6 on VAS, and improvement in functional capacity from 74.4 ± 12.0 to 83.5 ± 9.0 on FIM (Functional Independence Measure) in the follow-up period. Conclusion. Atypical corrective segmental vertebrectomy performed in the late period of spinal cord injury effectively eliminates post-traumatic deformity, and improves functional capacity of patients with complete neurological deficit.

Trauma of the External Popliteal Sciatic Nerve (SPE) Following a Dislocation of the Knee: About a Case

Knee dislocation is a translocation of the tibia with respect to the femur following a violent trauma. It can be complicated by serious vasculo-nervous lesions, of which the paralysis of the sciatic nerve poplite external remains infrequent. This is the case of our patient who presented six months ago a traumatic dislocation of the left knee reduced in urgency, And which was complicated by a complete neurological deficit of the SPE nerve, confirmed by electromyogram (EMG). Palliative surgery was indicated and was aimed at improving functional prognosis, using tendon transfer to resuscitate the dorsal flexion of the foot.