Lumbar Spine Fractures Research Articles

Management of spinal cord injury after traumatic spine fractures in a middle-aged welder

Traumatic spine fractures associated with injuries are uncommon but extremely severe that are known to cause significant long-term disability and socioeconomic burden. Therefore, the management after an injury is extremely crucial. We report a case of lumbar spine fracture complicated with cauda equina nerve injury. The patient had 2 years’ history of hypertension and type2 diabetes. American Spinal Injury Association (ASIA) impairment scale was Grade A. Surgeon performed posterior incision for reduction and decompression and spinal fusion with pedicle screw instrumentation at the L2–L3 level. Due to poor control of blood sugar and decreased resistance after the injury, post-operative incision healing was poor and infection occurred (Staphylococcus aureus). After debridement, drainage, and anti-infection treatment, the incision gradually healed. There was no neurological recovery on the saddle area and lower limbs even after 1 year.

Expression and clinical significance of receptor-interacting protein serine-threonine kinases 1 in the nucleus pulposus of patients with lumbar disc herniation

To investigate the expression and clinical significance of receptor interacting protein serine-threonine kinases 1 (RIPK1) in the nucleus pulposus of patients with lumbar disc herniation (LDH). Nucleus pulposus tissue specimens of 40 patients with LDH patients underwent surgical treatment from January 2016 to January 2018 as the case group, and nucleus pulposus tissue specimens of 30 patients with lumbar spine fracture underwent surgical treatment at the same time as the control group. The expression of RIPK1 mRNA and protein of receptor interaction were detected by polymerase chain reaction (PCR) and Western blot, respectively. The expression of RIPK1 protein in the nucleus pulposus were detected by immunohistochemical staining. The concentrations of RIPK1 and tumor necrosis factor-α (TNF-α) in nucleus pulposus were detected by ELISA method. The relationship between the concentrations of RIPK1, TNF-α in nucleus pulposus and the Pearce grade of LDH patients was analyzed by one-way ANOVA. The correlation between RIPK1 and TNF-α was analyzed by Pearson. RIPK1 was weakly positively expressed in nucleus pulposus of control group, and RIPK1 protein was positively or strongly positively expressed in case group. The expression of RIPK1 mRNA in nucleus pulposus of case group was higher than that of control group (P<0.05). The expression of RIPK1 protein in nucleus pulposus of case group was higher than that of control group(P<0.05). The RIPK1 concentration in nucleus pulposus of case group was higher than that of control group (P=0.012). The concentration of TNF-α in nucleus pulposus of case group was significantly higher than that of control group (P=0.009). There were significantdifferences in concentrations of RIPK1 and TNF-α in nucleus pulposus of LDH patients with different Pearce classification (P>0.05). The concentration of RIPK1 and TNF-α in nucleus pulposus increased significantly with the increase of Pearce grade. Pearson correlation analysis showed that there was a significant positive correlation between RIPK1 and TNF-α in nucleus pulposus of LDH patients (r=0.781, P<0.001). The expression levels of RIPK1 mRNA and protein in the intervertebral disc tissues of LDH patients are higher than those of normal intervertebral disc tissues, and increased with the increase of Pearce grade, which may be an important factor involved in LDH inflammatory disease.

Open reduction of thoraco-lumbar fractures and sagittal balance correction using Schanz screws

IntroductionThe correction of thoracic and lumbar spine fractures with a short instrumentation using Schanz screws, is an effective method for stabilization and sagittal balance restoration. Materials and methodsBidirectional observational study, included patients undergoing arthrodesis with Schanz screws to manage thoracic and lumbar fractures, the general characteristics, type, and location of the fracture, besides the gain in height of the vertebral body and segmental angle were analyzed before and after surgery. Clinical and imaging control was performed postoperatively and 1 month after this. p-value<.05 was statistically significant. ResultsOf 35 patients undergoing arthrodesis, 13 were excluded due to the absence of images and follow-up. There was a higher proportion of men, the main location of the fracture and AO spine classification was in T12 and type A4/B1 respectively, there was no intraoperative complication, no transfusion was required, and a short hospital stay. A mild complication was presented in the follow-up. The average pre and postoperative change was 12 degrees in the Cobb angle and 5.2mm vertebral body height in the fractured vertebra, these changes were statistically significant. ConclusionThoracolumbar and lumbar spine fracture correction with short segment fixation using Schanz screws, is an effective, safe and fast, showing significantly vertebral height gain and segmental angle correction, as a consequence, a correction of the balance and alignment of the spine.

Spinal fractures and/or spinal cord injuries are associated with orthopedic and internal organ injuries in proximity to the spinal injury

Backgroundthe demographics, mechanisms of injury, and concurrent injuries associated with cervical, thoracic and lumbar spinal fracture and/or spinal cord injury remain poorly characterized. MethodsPatients aged 18 and older with spinal injury between 2011 and 2015 in the National Trauma Data Bank (NTDB) were identified. Patient demographics, comorbidity burden, mechanism of injury, and associated injuries were analyzed. Resultsin total, 520,183 patients with acute spinal injury were identified including 216,522 cervical, 191,218 thoracic, and 220,294 lumbar. The age distributions were trimodal with peaks in incidence at around 2155 and a lesser peak around 85 years of age. The number of comorbidities increased while injury severity decreased with advancing patient age. Motor vehicle accidents (MVAs) were the most common mechanism of injury. Associated bony and internal organ injuries were common and occurred in 63% of cervical spine injury patients, 79% of thoracic spine injury patients, and 71% of lumbar spine injury patients. In all three sub-populations, there was a predominance of injuries in the local area of the primary injury. For cervical, these were rib injuries (28%), thoracic spine injuries (22%), skull fractures (20%), intracranial injuries (26%) and lung injuries (21%). For thoracic, these were rib injuries (47%), lumbar spine injuries (26%), cervical spine injuries (25%), lung injuries (35%) and intracranial injuries (24%). For lumbar, these were rib injuries (38%), thoracic spine injuries (22%), pelvic fractures (20%), lung injuries (26%) and intracranial injuries (19%). Multivariate regression analysis demonstrated that increased injury severity was strongly correlated with increased mortality, with lesser contributions from increased age and comorbidity burden. Conclusionsthe current study revealed spinal fractures and/or cord injuries had high incidences of associated injuries that had a predominance of local distribution. These findings, in combination with the mortality analysis, demonstrate the importance of local targeted evaluations for associated injuries.

Specimen-specific fracture risk curves of lumbar vertebrae under dynamic axial compression

Underbody blast attacks of military vehicles by improvised explosives have resulted in high incidence of lumbar spine fractures below the thorocolumbar junction in military combatants. Fracture risk curves related to vertical loading at individual lumbar spinal levels can be used to assess the protective ability of new injury mitigation equipment. The objectives of this study were to derive fracture risk curves for the lumbar spine under high rate compression and identify how specimen-specific attributes and lumbar spinal level may influence fracture risk. In this study, we tested a sample of three-vertebra specimens encompassing all spinal levels between T12 to S1 in high-rate axial compression. Each specimen was tested with a non-injurious load, followed by a compressive force sufficient to induce vertebral body fracture. During testing, bone fracture was identified using measurements from acoustic emission sensors and changes in load cell readings. Following testing, the fractures were assessed using computed tomographic (CT) imaging. The CT images showed isolated fractures of trabecular bone, or fractures involving both cortical and trabecular bone. Results from the compressive force measurements in conjunction with a survival analysis demonstrated that the compressive force corresponding to fracture increased inferiorly as a function of lumbar spinal level. The axial rigidity (EA) measured at the mid-plane of the centre vertebra or the volumetric bone mineral density (vBMD) of the vertebral body trabecular bone most greatly influenced fracture risk. By including these covariates in the fracture risk curves, no other variables significantly affected fracture risk, including the lumbar spinal level. The fracture risk curves presented in this study may be used to assess the risk of injury at individual lumbar vertebra when exposed to dynamic axial compression.

Negative correlation between bone mineral density and subclinical fractures in patients with human immunodeficiency virus.

BackgroundAlthough low bone mineral density (BMD) is associated with an increased risk of fracture, few studies have assessed fracture rates in patients with human immunodeficiency virus (HIV).MethodsThe occurrence of subclinical fractures in patients with HIV was assessed. Pearson’s chi-square test was used to analyze the relationship between subclinical fractures and related factors.ResultsFifty patients with HIV were included, among whom 11 were diagnosed with subclinical fractures. These 11 patients had a mean body mass index of 24.127 ± 3.482 kg/m2, smoked a mean of 142.091 ± 3.482 cigarettes/month, drank a mean of 61.545 ± 13.026 mL/day of alcohol, had a mean CD4+ T cell count of 247.727 ± 181.679 cells/mm3, had a mean duration of acquired immunodeficiency syndrome (AIDS) of 4.27 ± 0.786 years, and had a mean BMD of the third lumbar spine of 0.810 ± 0.063 g/cm3. The AIDS duration and BMD of the third lumbar spine were significantly associated with subclinical fractures. The BMD of the third lumbar spine was negatively correlated with subclinical fractures.ConclusionA significant negative correlation was found between the BMD of the third lumbar spine and subclinical fractures.

Reducción abierta de fracturas toracolumbares y corrección del balance sagital usando tornillos Schanz

IntroductionThe correction of thoracic and lumbar spine fractures with a short instrumentation using Schanz screws, is an effective method for stabilization and sagittal balance restoration. Materials and methodsBidirectional observational study, included patients undergoing arthrodesis with Schanz screws to manage thoracic and lumbar fractures, the general characteristics, type, and location of the fracture, besides the gain in height of the vertebral body and segmental angle were analyzed. before and after surgery. Clinical and imaging control was performed postoperatively and 1 month after this. p-value < .05 was statistically significant. ResultsOf 35 patients undergoing arthrodesis, 13 were excluded due to the absence of images and follow-up. There was a higher proportion of men, the main location of the fracture and AO spine classification was in T12 and type A4/B1 respectively, there was no intraoperative complication, no transfusion was required, and a short hospital stay. A mild complication was presented in the follow-up. The average pre and postoperative change was 12 degrees in the Cobb angle and 5.2 mm vertebral body height in the fractured vertebra, these changes were statistically significant. ConclusionThoracolumbar and lumbar spine fracture correction with short segment fixation using Schanz screws, is an effective, safe and fast, showing significantly vertebral height gain and segmental angle correction, as a consequence, a correction of the balance and alignment of the spine.

The Analgesic Efficacy of Erector Spinae Plane Blocks in Patients Undergoing Posterior Lumbar Spinal Surgery for Lumbar Fracture

To investigate the postoperative analgesic efficacy of ultrasound-guided lumbar erector spinae plane (ESP) blocks in patients undergoing posterior lumbar spinal surgery for lumbar spinal fractures. A total of 80 patients who were scheduled for posterior internal fixation for lumbar spinal fractures were divided into a patient-controlled analgesia (PCA) group or a combined ESP-PCA group. Numeric rating scale at rest and during movement, postoperative sufentanil consumption, and accumulative and effective bolus presses of PCA were recorded at 6, 12, 24, and 48 hours postoperatively. Numeric rating scale at rest and during movement was the primary outcome. Incidence of postoperative nausea and vomiting during the first 24-48 hours, pruritus and chronic postoperative pain, and dose of pethidine for rescue analgesia were also recorded. Numeric rating scale at rest and during movement at 6, 12, and 24 hours was lower in the ESP-PCA group (P < 0.001, P < 0.001, P= 0.0016 at rest; all P < 0.001 during movement). Lumbar ESP blocks diminished accumulative bolus presses and effective bolus presses of PCA at 6, 12, 24, and 48 hours postoperatively. Besides, patients in the ESP-PCA group had fewer demands for sufentanil and pethidine. The incidence of postoperative nausea and vomiting in the ESP-PCA group was lower than that in PCA group. PCA combined with lumbar ESP blocks provided superior postoperative analgesia for patients with lumbar spinal fractures treated with posterior internal fixation. Lumbar ESP blocks decreased postoperative opioid consumption and incidence of postoperative nausea and vomiting, thereby enhancing postoperative recovery.

Is There a Need for Abdominal CT Scan in Trauma Patients With a Low-Risk Mechanism of Injury and Normal Vital Signs?

BackgroundClinically significant injuries are often missed in trauma patients with low-risk mechanisms of injury and lack of "red flags," such as abnormal vital signs. The purpose of this retrospective analysis was to evaluate the efficacy of computed axial tomography (CT) for identifying occult injuries in a high-volume trauma center.MethodsRecords from our institutional trauma registry were retrospectively extracted, examining encounters from January 2015 to October 2019. Those patients between the ages of 18 and 65 who were referred to the trauma team with a CT scan of the abdomen and had low-risk mechanisms of injury, a Glasgow Coma Scale (GCS) score of 15, and normal vital signs at presentation were included. Patients in the lowest trauma categorization (Level Three, Consult) met the study definition for the low-risk mechanism of injury. Demographic and clinical data were abstracted for all patients. For this analysis, patients were divided into two groups based on age (18 - 40 years or 40 - 65 years). Injuries found on CT, their clinical significance, and the likelihood of being missed without CT were determined.ResultsOf 2,103 blunt trauma patients that received a CT scan of the abdomen from January 2015 to October 2019, 134/2,103 (6.4%) met the inclusion criteria (mean age: 44.6 years; 72.3% male). Patients between the ages of 40 and 65 years comprised 61.2% (82/134) of the study population. Of the included patients, 17.2% (23/134) had at least one acute traumatic injury identified after CT imaging of the torso. Occult injuries found on CT included rib fracture with associated lung injuries (10/23, 43.5%), splenic laceration (4/23, 17.4%), liver laceration (3/23, 13.0%), gluteal hematoma with active bleeding (1/23, 4.3%), sternal fractures (3/23, 13.0%), and thoracic or lumbar spine fractures (2/23, 8.7%). An independent review of the medical records determined that 9.0% (12/134) of these patients had traumatic injuries that would have been missed based on clinical examination without CT.ConclusionsBased on our experience, utilizing CT imaging of at least the abdomen as a routine screening measure for all trauma consults - even low-risk patients with normal vital signs - can rapidly and accurately identify clinically significant injuries that would have been otherwise missed in a notable portion of the population.

Traumatic lumbar spine fractures: Transverse process fractures dominate

PurposeWith motor vehicle collisions (MVC) predominating as a source of trauma now, we sought to 1) reassess the types of traumatic lumbar spine fractures, 2) highlight the coincidence of transverse process fractures (TPF) with visceral injuries and 3) emphasize the difference in management between compression fracture (CF) and TPF. MethodsWe retrospectively reviewed the reports of lumbar spine and abdominopelvic CT scans from 2017 and 2018 to classify the types of spine fractures, their mechanism of injury, treatment and coexistence of abdominopelvic injuries. Results2.2% of patients had posttraumatic lumbar spine fractures (113/5229), including 58 patients (51.3%) with isolated TPF and 42 (37.2%) with isolated CF; 13 patients had mixed types. TPF accounted for 70% of all fractures (195/277) as opposed to 24% for CF (67/277). MVC was responsible for 60.3% (35/58) of TPF but falls accounted for 73.8% (31/42) of CF. The odds ratio of having isolated TPF from MVC was 4.1[1.8–9.0] versus CF after a fall from standing was 4.5[2.0–10.5]. Of patients with both visceral injuries and lumbar spine fractures, 75% (27/36) had isolated TPF (odds ratio of visceral injury with TPF was 4.4[1.8–10.7]). No TPF were treated with an intervention, however 77% (40/52) of CF were addressed surgically or with braces. ConclusionTPF are the most common lumbar spine fractures and are often associated with MVC. There is a high association between TPF and abdominopelvic visceral injury requiring radiologists' attentiveness even though the TPF is not directly addressed.

Percutaneous transpedicular lumber fixation

Background: Posterior Pedicle screw fixation has step by step become popular to thoracolumbar fracture management. Since Roy-Camille et al used application of plates with pedicle screws for thoracolumbar fractures in 1963. Aim of the work: to evaluate the percutaneous transpedicular fixation for management of lumbar fractures. Patients and Methods: This research was done on 20 patients presented by lumbar spine fractures; they were treated with percutaneous transpedicular fixation and stabilization at Al-Azhar University hospitals from June 2019 to February 2020. All patients were without neurological deficits they were fixed either one level above and one level below or two levels above and two levels below the fractured vertebra. Results: Clinical and functional outcomes are preferable or comparable to conventional open procedures. The key disadvantages of this procedure are the steep learning curve and radiation exposure to both doctors, nurses and surly patients, which may be reduced as much as possible by using the new 3D CT screw insertion process. Conclusion: Percutaneous transpedicular spine fixation is a secure technique that follows the same principles as open procedures, allowing the surgeon to conduct biomechanically strong internal spinal fixation with minimal tissue damage, and is a suitable choice for the treatment of unstable thoracolimber fractures with no neurological deficit. This has the benefit of short-time surgery, no loss of blood, almost no muscle damage results in less postoperative pain than conventional open procedures, short hospitalization, early mobilization, a quicker return to work and a low risk of complications

Single-Stage Posterior Circumferential Stabilization Using Double Small Cages for the Treatment of Thoracic and Lumbar Spine Fractures

Controversy remains regarding the optimal methods for resection of the vertebral body, reconstruction of the anterior column, and decompression of the spinal cord in patients who have severe vertebral body destruction of the thoracic or lumbar spine with associated neurologic impairment. We report an alternative technique for primary treatment and salvage involving single-stage corpectomy followed by reconstruction of the anterior column using double small mesh cages via the posterior-only approach. Plain radiographs and computed tomography scans, taken at different intervals, were used to measure local kyphosis, segmental height, and fusion grade. Pain was evaluated using the visual analog scale (VAS), and neurologic symptoms were classified according to Frankel grade. The mean kyphotic deformity improved by 14.47 ± 9.06 degrees (P < 0.001), and the mean segmental height improved by 7.17 mm ± 6.11 mm (P < 0.001) after surgery. Fusion was achieved at 84% of patients, within a median interval of 12 months. Kyphotic recurrence was observed in 2 patients (11%), segmental height loss occurred in 1 patient (5%), and both kyphotic recurrence and segmental height loss occurred in 1 patient (5%). None of the patients reported worsening pain or neurologic symptoms after surgery, and there were no surgery-related complications such as neural injury, cerebrospinal fluid leakage, cage dislocation, surgical site infection, or cardiopulmonary complications. Single-stage corpectomy followed by reconstruction of the anterior column using double small mesh cages via the posterior-only approach is a reliable and less invasive single-stage treatment and salvage option in selected cases.

Fracture risk assessment in an Italian group of transgender women after gender-confirming surgery.

Bone health is a critical issue in transgender women (TW) health care. Conflicting results have been reported on bone status after gender-confirming surgery (GCS). No recent data in Italian TW are available. The aim of this cross-sectional study was to evaluate fracture risk, lumbar spine BMD and 25OH vitamin D (25OHD) levels in a population of TW on estrogen replacement therapy (ERT) after GCS. We retrospectively analyzed a group of 57 TW, aged 45.3 ± 11.3years, referred to our Gender Dysphoria Clinic, at least 2years after GCS. Anthropometric parameters, patient compliance to ERT, biochemical and hormonal assessment, lumbar spine BMD and fracture risk were evaluated. Prevalence of low bone mass (Z-score ≤ -2) was 40% according to the natal gender. In this group, 17β-estradiol levels were significantly lower (median 21pg/ml [25th-75th percentile 10.6-48.5] vs 63pg/ml [38.5-99.5]; p < 0.001) and a higher prevalence of low compliance to ERT was recorded (83% vs 29%; p < 0.0001) compared to those with higher bone mass. An intermediate-high fracture risk was found in 14% of the sample. A high percentage (93%) of hypovitaminosis D was present. TW on ERT have a high prevalence of low bone mass, significantly associated with low estradiol levels and low compliance to ERT. A high prevalence of hypovitaminosis D was highlighted. Considering that one out of seven TW showed an intermediate-high 10-year fracture risk, such risk assessment may be considered to prevent and manage osteoporosis in this clinical setting.

Correlation of history and physical examination with imaging in traumatic near-shore aquatic head and spinal injury

ObjectiveIt remains unclear whether clinicians can rely on specific symptoms and signs to detect or exclude serious head and spinal injury sustained during near-shore aquatic activities. Our study investigated patients' history of present illness (HPI) and physical examination (PE) for their utility in detecting serious head and spinal injury. MethodsWe conducted a multicenter retrospective comparative analysis of adult patients who were transported from the beach in Ocean City, Maryland, to three nearby emergency departments for possible spinal injury from 2006 through 2017. Patients suspected to have any spinal injury from beach activities were eligible. We excluded patients who could not verbalize their symptoms or with insufficient emergency department records. We compared components of each patient's HPI and PE with radiologic evidence of spinal injury. We calculated sensitivity, specificity, and negative and positive likelihood ratios (LRs). ResultsWe analyzed 278 patients with suspected spinal injury. Midline spinal tenderness was associated with increased likelihood of thoracic (LR+ 2.6) and lumbar spinal fractures (LR+ 3.5). HPI complaints of paralysis (LR+ 13.9) and sensory loss (LR+ 5.8) had strong associations with spinal cord injuries. Weakness found through PE was also associated with spinal cord injury (LR+ 5.3). ConclusionsWe identified several components of the clinical evaluation that had clinically significant association with spinal injuries from beach-related trauma. While prospective studies are needed to confirm our observations, clinicians may consider these high-risk features in patients with beach-related trauma and adjust testing and level of care appropriately.

Radiological Risk Factors for Neurological Deficits After Traumatic Mid and Low Lumbar Fractures.

Retrospective study. We identified radiological risk factors for neurological deficits in mid and low lumbar spinal fractures. Although numerous studies have focused on radiological risk factors for neurological deficits in spinal cord injury or thoracolumbar junction area fractures, few have examined mid and low lumbar fractures at the cauda equina level. We retrospectively reviewed 71 consecutive patients who suffered acute traumatic mid and low lumbar fractures (L2-L5) corresponding to the cauda equina level, as confirmed on magnetic resonance imaging. We defined a neurological deficit as present if the patient had any sensory or motor deficit in the lower extremity or autonomic system at the initial assessment. Various computed tomography parameters of canal stenosis, vertebral body compression, sagittal alignment, interpedicular distance, and presence of vertical laminar fractures were analyzed as independent risk factors to predict neurological deficits using multivariate logistic regression analyses. At the initial assessment, 31 patients had neurological deficits. Fracture level, AO fracture type, canal encroachment ratio, vertebral compression ratio, interpedicular distance ratio, and presence of a vertical laminar fracture were significantly associated with the presence of neurological deficits (all P < 0.05). Multivariate logistic regression identified fracture level, canal encroachment ratio (adjusted odds ratio [aOR] 1.072, 95% confidence interval [CI] 1.018-1.129), and vertebral compression ratio (aOR 0.884, 95% CI 0.788-0.992) as independent predictors of a neurological deficit. Receiver operating characteristic curve analyses revealed that only the canal encroachment ratio had good discriminatory ability (area under the curve 0.874, 95% CI 0.791-0.957), and the optimal cutoff was 47% (canal diameter 6.6 mm) with 90.3% sensitivity and 80% specificity. The canal encroachment ratio was most strongly associated with neurological deficits in traumatic mid and low lumbar fractures, with an optimal cutoff of 47%. 4.

Kitesurf injury trauma evaluation study: A prospective cohort study evaluating kitesurf injuries.

Kitesurfing is an increasingly popular and potentially dangerous extreme water sport. We hypothesized that kitesurfing has a higher injury rate than other (contact) sports and that the minority of injuries are severe. To investigate the incidence and epidemiology of kitesurfing injuries in a Dutch cohort during a complete kitesurfing season. Injury data of 194 kitesurfers of various skill levels, riding styles and age were surveyed prospectively during a full kitesurf season. The participants were recruited through the Dutch national kitesurf association, social media, local websites and kitesurf schools. Participants completed digital questionnaires monthly. The amount of time kitesurfing was registered along with all sustained injuries. If an injury was reported, an additional questionnaire explored the type of injury, injury location, severity and the circumstances under which the injury occurred. The mean age of participants was 31 years (range, 13-59) and the majority of the study population was male (74.2%). A total of 177 injuries were sustained during 16816 kitesurf hours. The calculated injury rate was 10.5 injuries per 1000 h of kitesurfing. The most common injuries were cuts and abrasions (25.4%), followed by contusions (19.8%), joint sprains (17.5%) and muscle sprains (10.2%). The foot and ankle were the most common site of injury (31.8%), followed by the knee (14.1%) and hand and wrist (10.2%). Most injuries were reported to occur during a trick or jump. Although the majority of injuries were mild, severe injuries like an anterior cruciate ligament tear, a lumbar spine fracture, a bimalleolar ankle fracture and an eardrum rupture were reported. The injury rate of kitesurfing is in the range of other popular (contact) sports. Most injuries are relatively mild, although kitesurfing has the potential to cause serious injuries.

Fusion Surgery for Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

Lumbar spine stenosis represents a complex degenerative pathology that has been a subject of significant dispute when it comes to fusion. A review of the literature from 2008 to 2019 was performed on the role of fusion in the treatment of lumbar spinal stenosis using PubMed, Ovid Medline, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Using the key words “lumbar spinal stenosis,” “lumbar fusion,” “lumbar decompression,” and “lumbar pedicle screw fixation,” the search revealed 490 papers. Of these, only Level 1 or Level 2 evidence papers were selected, leading to only 3 randomized controlled trials (RCTs) that were analyzed. None of the good-quality studies (RCTs) performed so far have proven any clinical benefit of adding fusion to degenerative lumbar spine decompression. The effect of spinal instability on the outcome following decompression remains controversial. At present, no unanimous criteria exist among the RCTs to identify what constitutes true instability. Fusion for instability or stenosis alone remains controversial, and the results are unconvincing. At this point, the issue expands to not only lumbar degenerative diseases but spinal fractures and lumbar isthmic spondylolisthesis. We thereby present the consensus of the World Federation of Neurosurgical Societies Spine Committee, which formulated the indications for lumbar spine fusion in degenerative lumbar stenosis.

Long-term Behavior of Single-level Thoracic and Lumbar Fractures Treated With Pedicle Screw Fixation.

This was a retrospective cohort study to objectively analyze the behavior of single-level thoracic (T), thoracolumbar (TL), and lumbar (L) fractures treated with posterior instrumentation alone and to understand which factors influence the ability to restore and maintain normal spinal alignment. Posterior screw fixation of dorsal and lumbar spine fractures allows fracture stabilization, correction of kyphotic deformity and restoration of vertebral height. The load-sharing classification identifies fractures that may need anterior instrumentation. Patients submitted to pedicle screw fixation of single-level T, TL, and L fractures were retrospectively analyzed. Data on patient demographics, neurological injury [American Spinal Injury Association (ASIA) score], and comorbidities were collected. Fractures were classified according to their anatomic region (T, TL, or L) and using the AO Spine and the load-sharing classifications. Local kyphosis angle, Cobb angle (CA), and changes in anterior vertebral height (AVH) were measured, to quantify intraoperative correction and loss of correction at 6 weeks and at last follow-up. A multivariate analysis was performed to identify the factors influencing the intraoperative correction and the loss of correction over time. From a total of 230 fractures, 115 patients with a mean age of 51.48 years were included. Pedicle screw fixation achieved a significant intraoperative correction of the CA, local kyphosis angle, and AVH. This correction was partially lost over time, but, at last follow-up, radiographic parameters were still significantly better than preoperatively. A regression model identified that age and body mass index influenced the correction of CA; ASIA classification influenced the correction of AVH. Posterior screw fixation allows for the restoration of spinal alignment, but this correction is less effective in elderly people and in patients with higher body mass index and higher degree of neurological injury.Level of Study: Level III.

No Need for Sternal Fixation in Traumatic Sternovertebral Fractures: Outcomes of a 10-Year Retrospective Cohort Study.

Study Design:Retrospective cohort study.Objectives:Combined sternal and spinal fractures are rare traumatic injuries and present a high risk of spinal and thoracic wall instability. Limited research has addressed the treatment of sternovertebral injuries and biomechanical need for sternal fixation to achieve spinal healing.Methods:A 10-year retrospective cohort study was conducted, including patients with sternovertebral fractures admitted to our level-1 trauma centre between 2007 and 2016. Patients who died during hospital admission, military patients, patients with isolated upper cervical spine or lower lumbar spine fractures, and patients lost to follow-up were excluded.Results:In 10 years, 73 patients with sternovertebral fractures were included. Mean injury severity score was 24 (range 4-57). Most sternal fractures were located in the sternal body and manubrium. Spinal fractures were type A (52%), B (40%), or C (8%), and were located in the subaxial cervical (21%), upper thoracic (16%), thoracic (21%), thoracolumbar (47%) area; 7 patients had spinal fractures at multiple levels. Fourteen patients (19%) had a neurological deficit. A total of 42 patients received conservative and 31 patients received operative spinal treatment. Two patients (3%) underwent primary sternal fixation. Sternal failure rate was 1% and biomechanical spinal failure rate was 8%, there was no difference in treatment failure between surgical and conservative spinal treatment. Associated thoracic injuries did not influence sternal or spinal treatment outcomes.Conclusions:These findings indicate that conservative sternal treatment in presence of spinal fractures is safe and effective. The low spinal treatment failure rates imply that sternal fixation is not necessary to achieve spinal stability.

Association between osteoporotic femoral neck fractures and DXA-derived 3D measurements at lumbar spine: a case-control study.

The aim of the present study was to evaluate the association between DXA-derived 3D measurements at lumbar spine and osteoporotic hip fractures. We analyzed a case-control database composed by 61 women with transcervical hip fractures and 61 age-matched women without any type of fracture. DXA scans at lumbar spine were acquired, and areal bone mineral density (aBMD) was measured. Integral, trabecular and cortical volumetric BMD (vBMD), cortical thickness, and cortical surface BMD (sBMD) at different regions of interest were assessed using a DXA-based 3D modeling software. Descriptive statistics, tests of difference, odds ratio (OR), and area under the receiver operating curve (AUC) were used to compare hip fracture and control groups. Integral vBMD, cortical vBMD, cortical sBMD, and cortical thickness were the DXA-derived 3D measurements at lumbar spine that showed the stronger association with transcervical hip fractures, with AUCs in the range of 0.685-0.726, against 0.670 for aBMD. The highest AUC (0.726) and OR (2.610) at the lumbar spine were found for integral vBMD at the posterior vertebral elements. Significantly, lower AUC (0.617) and OR (1.607) were found for trabecular vBMD at the vertebral body. Overall, total femur aBMD remains the DXA-derived measurement showing the highest AUC (0.838) and OR (6.240). This study showed the association of DXA-derived measurements at lumbar spine with transcervical hip fractures. A strong association between vBMD at the posterior vertebral elements and transcervical hip fractures was observed, probably because of global deterioration of the cortical bone. Further studies should be carried out to investigate on the relative risk of transcervical fracture in patients with long-term cortical structural deterioration.