Lumbar Spine Trauma Research Articles

Clinical application and cases examples of a new treatment algorithm for treating thoracic and lumbar spine trauma.

Review of illustrative cases of a new algorithm to help in the treatment decision of thoracolumbar spine trauma. To illustrate the use of the new algorithm for managing thoracic and lumbar spine trauma. Recently, a new algorithm for helping in the decision of the best treatment modality for thoracolumbar spine trauma (TLST) was published. The algorithm considers injury morphology, neurological status, clinical status (pain and disability), and also multimodal radiological evaluation (MMRE) in the decision for non-operative versus operative treatment for TLST. Injuries were classified in three groups: (1) stable injuries, (2) potentially unstable injuries/ delayed instability, or (3) clearly unstable injuries. Cases examples of the algorithm application were presented and discussed. Stable injuries (minor fractures without instability) are non-surgically treated; potentially unstable injuries or associated with delayed instability may be initially managed non-surgically and operative treatment is an option, especially in the setting of important pain, deformity or a new neurological deficit. Clearly unstable injuries are treated surgically as soon as possible to avoid neurological worsening, severe pain, and/ or progressive spinal deformity. Clinical examples of TLST were presented, discussed and classified as stable, potentially unstable and clearly unstable injuries. Further studies addressing the reliability and safety of this algorithm are necessary.

Epidemiological Characteristics of Dorsal and Lumbar Spine Trauma Presenting to a Trauma Hospital in Kathmandu, Nepal: Formulation of a National Spine Policy.

Introduction Outcome of spine injury treated in resource constrained regions may not be the same as in developed nations. The aim of the present study was to study the epidemiological characteristics, delay, complications, and outcome of surgically treated dorsal and lumbar trauma. Methods Retrospective study of dorsal and lumbar spine injury patients treated between December 2015 and August 2017. Patients were segregated into four groups based on the timing of surgery: 0-2 days, 3-7 days, 8-30 days, and more than 31 days. Only one operating room twice a week was allotted to spine surgery, and spine had to compete with orthopedic and surgical trauma for admission and surgery. Results Ninety-one patients (male 61) with mean age 33 years were operated for dorsal and lumbar spine injuries. 84% of the total patients sustained a fall, and 86.8% were from the periphery. Though 69.2% presented within 2 days, only 4.4% were operated within 2 days. Majority of the delay was due to unavailability of the operating room followed by financial constraints. Twenty-seven patients had complete deficit, 32 incomplete deficit, and 32 normal neurology. Four patients operated within 2 days improved their neurology, 7 incomplete deficit patients in 3-7 days group improved, 6 in 8-30 days group improved, whereas no patient in more than 31 days group improved. Overall 53.1% of neurologically incomplete deficit patients improved if operated within 30 days. No neurological improvement was seen in the 27 complete deficit patients. Wound infection, pulmonary contusion, and deep vein thrombosis were seen in 3 patients. Conclusions As expected 95.6% of our patients were treated more than 3 days after injury and 60% more than a week later, which may not be acceptable in advanced countries. Despite the delay, 53.1% had an improvement in neurology when operated within 30 days. Hence, surgery still holds the hope of neurological recovery and quicker rehabilitation.

Correlation between clinical and imaging finding of symptomatic degenerative lumbar spine disease

Background: Back pain resulting from degenerative disease of the spine is one of the most common causes of disability in working age adults. Clinical symptomatology of these patients varies widely with imaging findings. Materials and Methods: This study was conducted in Burdwan Medical College and Hospital. Study Population: Inclusion criteria: (a) Patient age ≥35 years (b) Clinically suffering from degenerative lumbar spine disease (c) Imaging evidence were included in the study. Exclusion criteria: (a) Traumatic lumbar spine, metastatic disease, previous neurovascular pathology, or associated lower limb fractures were excluded from the study. Sample Size: Two hundred patients were included in the study. Study Design: This was an institution-based cross-sectional study. Study Tools: All cases have undergone X-ray, but magnetic resonance imaging has been most effective. Data Analysis: For statistical analysis, we have calculated Chi-square statistic value and P value. Results: In this study, single disc involvement (49.4%) and multiple disc involvement (50.6%) pattern was equally prevalent. For single level disc changes, disc bulge was the most common pathology in our study (75%) followed by disc protrusion (25%). Among the patients with severe degree of nerve compression, 72.9% of patients had claudication. In our study, 81% of patients with anteroposterior (AP) canal diameter Conclusion: There has been positive correlation between clinical and imaging finding for severe degree of disc degeneration and spinal canal stenosis but variable for DSL.

Role of LncRNA TUG1 in intervertebral disc degeneration and nucleus pulposus cells via regulating Wnt/β-catenin signaling pathway

ObjectiveTo investigate the role of TUG1 in intervertebral disc degeneration (IDD) and human nucleus pulposus cells (NPCs) via regulating Wnt/β-catenin pathway. MethodsThe study collected nucleus pulposus (NP) tissue samples from 30 patients with lumbar disc herniation (LDH) (Case group) and 18 patients with lumbar spine trauma (Control group). NPCs induced by TNF-α in vitro were divided into Blank, Vector, TUG1, TUG1-siRNA, XAV-939, TUG1 + XAV-939 groups. qRT-PCR was used to detect the expression of TUG1 and ECM-related genes, Western blot to determine the expression of Wnt/β-catenin pathway and apoptosis-related proteins, and ELISA to measure the expression of ECM-related proteins. The apoptosis was detected by TUNEL and Annexin V-FITC/PI double-staining. The proliferation and senescence were tested by CCK-8 and SA-β-gal staining respectively. ResultsTUG1 was upregulated in patients with IDD, which was positively related to Wnt and β-catenin. Besides, TUG1, Wnt1 and β-catenin were greatly increased in the NPCs after TNF-α induction. Compared with the Blank group, TUG1-siRNA and XAV-939 can appreciably down-regulate the expressions of Wnt1, β-catenin, Caspase-3, Bax, MMP3 and ADAMTS5, up-regulate the expression of Bcl-2, Aggrecan and COL2A1, inhibit the apoptosis and senescence, and promote cell proliferation; however, the TUG1 group had the completely opposite results. ConclusionSilencing TUG1 may not only protect human NPCs from TNF-α-induced apoptosis and senescence, but also promote cell proliferation by blocking Wnt/β-catenin pathway, which provides a theoretical basis for the clinical treatment of IDD.

A Study of Traumatic Dorsal and Lumbar Vertebral Injuries with Neurological Deficit

Abstract Introduction It has been reported that 6% of all fractures affect the spinal column, and 90% of them are found in the thoracic or lumbar regions. However, information on traumatic SCI is minimal for developing countries. Therefore, we conducted this study to determine the pattern, causes and surgical outcome of dorsal and lumbar spine trauma in the rural Indian population. Methods 21 patients who were admitted with a diagnosis of thoracic or lumbar spine injury were studied. There were 15 males and 6 females with an average age of 41.6 years. All the patients were followed over a minimum period of 18 months and the results were analyzed. Results Most of the patients belonged to the labourer group, both industrial and farm labourers, constituting 57.14%. The average duration of injury to admission is 2.5 days. Fall from height (FFH) was the leading cause of spine injury and constituted 61.91%. The dorso-lumbar junction, i.e. D11, D12, L1 and L2, was the most affected, constituting 66.66% of all the injuries. In most of the fractures, stabilization was done with 2 pairs of pedicle screws (one proximal and one distal), as in 17 out of 19 operated patients (89.48%). The average follow-up duration was 22 months. According to our result assessment criteria, 55% of the patients had excellent-to-good result at final follow-up. Conclusion The number of screws used had no co-relation with the kyphosis correction and neurological outcome of the patient and fusion is not mandatory to maintain the correction of deformity.

Universal disease-specific outcome instruments for spine trauma: a global perspective on relevant parameters to evaluate clinical and functional outcomes of thoracic and lumbar spine trauma patients

PurposeBesides a patient reported outcome measure, the AOSpine Knowledge Forum Trauma aims to develop a new concept of a surgeon reported outcome measure (SROM) for spine trauma patients. This study aims to identify parameters that spine surgeons consider relevant to evaluate clinical and functional outcomes of thoracic and lumbar spine trauma patients.MethodsAn international cross-sectional web-based survey was conducted among spine surgeons from the five AOSpine International world regions. They were asked to evaluate the relevance of a compilation of 16 clinical and radiological parameters for thoracic and lumbar spine trauma patients, both for the short term (3 months–2 years) and long term (≥2 years), on a five-point scale. The responses were analyzed using descriptive statistics, frequency analysis, and Kruskal–Wallis test.ResultsOut of the 279 invited members of AOSpine International and the International Spinal Cord Society, 118 (42.3 %) participated in this study. Of the 16 surveyed parameters, 5 were identified as relevant by at least 70 % of the participants. Neurological status was identified as most relevant. In contrast, five parameters were not deemed relevant for any spine region or time period, except for comorbidity. Only minor differences were observed when analyzing the responses according to each world region, spine surgeons’ clinical experience, or professional background.ConclusionsIncluding a large and representative sample of spine trauma experts, this study identified parameters to evaluate clinical and functional outcomes of thoracic and lumbar spine trauma patients. The results form the basis for the development of a SROM for this specific patient population.

Communicating Hydrocephalus Due to Traumatic Lumbar Spine Injury: Case Report and Literature Review.

: Hydrocephalus is a rare complication of traumatic spine injury. A literature review reflects the rare occurrence with cervical spine injury. We present a case of traumatic injury to the lumbar spine from a gunshot wound, which caused communicating hydrocephalus. The patient sustained a gunshot wound to the lumbar spine and had an L4-5 laminectomy with exploration and removal of foreign bodies. At the time of surgery, the patient was found to have dense subarachnoid hemorrhage in the spinal column. He subsequently had intermittent headaches and altered mental status that resolved without intervention. The headaches worsened, so a computed tomography scan of the brain was obtained, which revealed hydrocephalus. A ventriculoperitoneal shunt was placed, and subsequent computed tomography scan of the brain showed reduced ventricle size. The patient returned to rehabilitation with complete resolution of hydrocephalus symptoms. Intrathecal hemorrhage with subsequent obstruction or decreased absorption of cerebrospinal fluid at the distal spinal cord was thought to lead to communicating hydrocephalus in this case of lumbar penetrating trauma. In patients with a history of hemorrhagic, traumatic spinal injury who subsequently experience headaches or altered mental status, hydrocephalus should be included in the differential diagnosis and adequately investigated.

Multicenter retrospective evaluation of the validity of the Thoracolumbar Injury Classification and Severity Score system in children.

OBJECTIVE The Thoracolumbar Injury Classification and Severity Score (TLICS) system was developed to streamline injury assessment and guide surgical decision making. To the best of the authors' knowledge, external validation in the pediatric age group has not been undertaken prior to this report. METHODS This study evaluated the use of the TLICS in a large retrospective series of children and adolescents treated at 4 pediatric medical centers (Texas Children's Hospital, Children's Healthcare of Atlanta, Riley Children's Hospital, and Doernbecher Children's Hospital). A total of 147 patients treated for traumatic thoracic or lumbar spine trauma between February 1, 2002, and September 1, 2015, were included in this study. Clinical and radiographic data were evaluated. Injuries were classified using American Spinal Injury Association (ASIA) status, Denis classification, and TLICS. RESULTS A total of 102 patients (69%) were treated conservatively, and 45 patients (31%) were treated surgically. All patients but one in the conservative group were classified as ASIA E. In this group, 86/102 patients (84%) had Denis type compression injuries. The TLICS in the conservative group ranged from 1 to 10 (mean 1.6). Overall, 93% of patients matched TLICS conservative treatment recommendations (score ≤ 3). No patients crossed over to the surgical group in delayed fashion. In the surgical group, 26/45 (58%) were ASIA E, whereas 19/45 (42%) had neurological deficits (ASIA A, B, C, or D). One of 45 (2%) patients was classified with Denis type compression injuries; 25/45 (56%) were classified with Denis type burst injuries; 14/45 (31%) were classified with Denis type seat belt injuries; and 5/45 (11%) were classified with Denis type fracture-dislocation injuries. The TLICS ranged from 2 to 10 (mean 6.4). Eighty-two percent of patients matched TLICS surgical treatment recommendations (score ≥ 5). No patients crossed over to the conservative management group. Eight patients (8/147, 5%) had a calculated TLICS of 4, which meant they were candidates for surgery or conservative therapy by TLICS criteria. Excluding these patients, the degree of agreement between TLICS and surgeon decision was deemed to be very good (κ = 0.878). CONCLUSIONS The TLICS results and recommendations matched treatment in 96% of conservative group cases. In the surgical group, TLICS recommendations matched treatment in 93% of cases. The TLICS recommendations and surgeon decision making displayed very good concordance. The TLICS appears to be effective in the classification of thoracic and lumbar spine injuries and in guiding treatment in the pediatric age group.

Traumatic lumbar spondylolisthesis without facet fracture at L4/L5. A case report and literature review

L4–L5 traumatic spondylolisthesis has been rarely reported in the literature. At lumbar spine level traumatic dislocation lesion realizes “traumatic spondylolisthesis or traumatic bilateral lumbar facet locked syndrome”. The aim of the present paper is to report this rare lesion and discuss its mechanism and management. A case report is followed by Literature review made on Medline and scholar google database from 2000 to 2015. The case report concerned a 33-year-old man, who refused to wear a seat belt, injured his lumbar spine following a motor vehicle accident. L4-L5 spondylolisthesis occurred after the vehicle rolled over several times. Sixteen months after the accident the patient had a favorable outcome. Literature review on Medline and scholar google database from 2000 to 2015 was carried out and five cases of traumatic spondylolisthesis were found. The Sex ratio was 3/2. Surgical treatment consisted of posterolateral interbody fusion. Traumatic lumbar spine spondylolisthesis is rare. When it occurs, it is always associated with vertebral lumbar fracture. L4-L5 traumatic spondylolisthesis was caused by a high-energy mechanism and improper use of seat belt.

Phase 1 Trial of Autologous Bone Marrow Stem Cell Transplantation in Patients with Spinal Cord Injury.

Introduction. A total of 18 patients, with complete motor deficits and paraplegia caused by thoracic and lumbar spine trauma without muscle atrophy or psychiatric problems, were included into this study. Materials and Methods. The bone marrow was aspirated from the anterior iliac crest under local anesthesia and the mononuclear fraction was isolated by density gradient method. At least 750 million mononuclear-enriched cells, suspended in 2 mL of saline, were infused intrathecally. Results and Discussion. The study reports demonstrated improvement of motor and sensory functions of various degrees observed in 9 of the 18 (50%) cases after bone marrow stem cell transplantation. Measured by the American Spinal Injury Association (ASIA) scale, 7 (78%) out of the 9 patients observed an improvement by one grade, while two cases (22%) saw an improvement by two grades. However, there were no cases in which the condition was improved by three grades. Conclusions. Analysis of subsequent treatment results indicated that the transplantation of mononuclear-enriched autologous BMSCs is a feasible and safe technique. However, successful application of the BMSCs in the clinical practice is associated with the necessity of executing more detailed examinations to evaluate the effect of BMSCs on the patients with spinal cord injury.

Outcomes and National Trends for the Surgical Treatment of Lumbar Spine Trauma.

Introduction. Operative treatment of lumbar spine compression fractures includes fusion and/or cement augmentation. Our aim was to evaluate postoperative differences in patients treated surgically with fusion, vertebroplasty, or kyphoplasty. Methods. The Nationwide Inpatient Sample Database search for adult vertebral compression fracture patients treated 2004–2011 identified 102,316 surgical patients: 30.6% underwent spinal fusion, 17.1% underwent kyphoplasty, and 49.9% underwent vertebroplasty. Univariate analysis of patient and hospital characteristics, by treatment, was performed. Multivariable analysis was used to determine factors associated with mortality, nonroutine discharge, complications, and patient safety. Results. Average patient age: fusion (46.2), kyphoplasty (78.5), vertebroplasty (76.7) (p < .0001). Gender, race, household income, hospital-specific characteristics, and insurance differences were found (p ≤ .001). Leading comorbidities were hypertension, osteoporosis, and diabetes. Risks for higher mortality (OR 2.0: CI: 1.6–2.5), nonroutine discharge (OR 1.6, CI: 1.6–1.7), complications (OR 1.1, CI: 1.0–1.1), and safety related events (OR 1.1, CI: 1.0–1.1) rose consistently with increasing age, particularly among fusion patients. Preexisting comorbidities and longer in-hospital length of stay were associated with increased odds of nonroutine discharge, complications, and patient safety. Conclusions. Fusion patients had higher rates of poorer outcomes compared to vertebroplasty and kyphoplasty cohorts. Mortality, nonroutine discharge, complications, and adverse events increased consistently with older age.

Perioperative morbidity and mortality after lumbar trauma in the elderly.

OBJECT Traumatic fractures of the thoracolumbar spine are common injuries, accounting for approximately 90% of all spinal trauma. Lumbar spine trauma in the elderly is a growing public health problem with relatively little evidence to guide clinical management. The authors sought to characterize the complications, morbidity, and mortality associated with surgical and nonsurgical management in elderly patients with traumatic fractures of the lumbar spine. METHODS Using the National Sample Program of the National Trauma Data Bank, the authors performed a retrospective analysis of patients ≥ 55 years of age who had traumatic fracture to the lumbar spine. This group was divided into middle-aged (55-69 years) and elderly (≥ 70 years) cohorts. Cohorts were subdivided into nonoperative, vertebroplasty or kyphoplasty, noninstrumented surgery, and instrumented surgery. Univariate and multivariable analyses were used to characterize and identify predictors of medical and surgical complications, mortality, hospital length of stay, ICU length of stay, number of days on ventilator, and hospital discharge in each subgroup. Adjusted odds ratios, mean differences, and associated 95% CIs were reported. Statistical significance was assessed at p < 0.05, and the Bonferroni correction for multiple comparisons was applied for each outcome analysis. RESULTS Between 2003 and 2012, 22,835 people met the inclusion criteria, which represents 94,103 incidents nationally. Analyses revealed a similar medical and surgical complication profile between age groups. The most prevalent medical complications were pneumonia (7.0%), acute respiratory distress syndrome (3.6%), and deep venous thrombosis (3%). Surgical site infections occurred in 6.3% of cases. Instrumented surgery was associated with the highest odds of each complication (p < 0.001). The inpatient mortality rate was 6.8% for all subjects. Multivariable analyses demonstrated that age ≥ 70 years was an independent predictor of mortality (OR 3.16, 95% CI 2.77-3.60), whereas instrumented surgery (multivariable OR 0.38, 95% CI 0.28-0.52) and vertebroplasty or kyphoplasty (OR 0.27, 95% CI 0.17-0.45) were associated with decreased odds of death. In surviving patients, both older age (OR 0.32, 95% CI 0.30-0.34) and instrumented fusion (OR 0.37, 95% CI 0.33-0.41) were associated with decreased odds of discharge to home. CONCLUSIONS The present study confirms that lumbar surgery in the elderly is associated with increased morbidity. In particular, instrumented fusion is associated with periprocedural complications, prolonged hospitalization, and a decreased likelihood of being discharged home. However, fusion surgery is also associated with reduced mortality. Age alone should not be an exclusionary factor in identifying surgical candidates for instrumented lumbar spinal fusion. Future studies are needed to confirm these findings.

Communicating Hydrocephalus due to Traumatic Lumbar Spine Injury: Case Report and Literature Review

Hydrocephalus is a rare complication of traumatic spine injury. A literature review of hydrocephalus in traumatic spine injury reflects the rare occurrence with cervical spine injury. In the spinal cord tumor literature, distal thoracolumbar tumors are known to cause hydrocephalus. In our literature review, there have been no published cases or reviews of a traumatic injury distal to the cervical spine causing hydrocephalus. We present a case of traumatic injury to the lumbar spine from a gunshot wound which caused communicating hydrocephalus. The patient sustained a gunshot wound to the lumbar spine and had an L4-5 laminectomy with exploration and removal of foreign bodies. At the time of surgery, the patient was found to have dense subarachnoid hemorrhage in the spinal column. He subsequently had intermittent headaches and altered mental status that resolved without intervention. Workup of the headaches for infection including lumbar tap was performed which revealed no growth. The patient was discharged to an acute rehabilitation facility and had followup 20 days later. Follow up CT of the lumbar spine was significant for interim development of a traumatic lumbar pseudomeningocele. The intermittent headaches had been worsening while in rehabilitation so a CT Brain was performed which revealed hydrocephalus and the patient was emergently transferred to the neurosurgery service. IR-guided cervical spinal tap was performed that again did not demonstrate meningitis. A ventricle peritoneal shunt was placed and repeat CT Brain showed reduced ventricle size. The patient returned to rehabilitation with complete resolution of hydrocephalus symptoms. Conclusion: Remote subarachnoid hemorrhage with subsequent arachnoiditis causing obstruction at the level of the arachnoid granulations was thought to lead to communicating hydrocephalus in this case of lumbar spine penetrating trauma. Hydrocephalus should be on the headache and/or altered mental status differential in a bloody, traumatic spinal injury.

Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma

Thoracolumbar and lumbar trauma account for the majority of traumatic spinal injuries. The mainstay of current treatments is still nonoperative therapy with bracing. Classic treatment algorithms reserved absolute surgical intervention for spinal trauma patients with neurological compromise or instability. Relative indications included incapacitating pain and obesity/body habitus making brace therapy ineffective. In the past decade, minimally invasive surgical (MIS) techniques for spine surgery have been increasingly used for degenerative conditions. These same minimally invasive techniques have seen increased use in trauma patients. The goal of minimally invasive surgery is to decrease surgical morbidity through decreased soft-tissue dissection while providing the same structural stability afforded by classic open techniques. These minimally invasive techniques involve percutaneous posterior pedicle fixation, vertebral body augmentation, and utilization of endoscopic and thoracoscopic techniques. While MIS techniques are somewhat in their infancy, an increasing number of studies are reporting good clinical and radiographic outcomes with these MIS techniques. However, the literature is still lacking high-quality evidence comparing these newer techniques to classic open treatments. This article reviews the relevant literature regarding minimally invasive spine surgery in the treatment of thoracolumbar and lumbar trauma.

Operative and nonoperative adverse events in the management of traumatic fractures of the thoracolumbar spine: a systematic review.

Thoracolumbar spine injuries are commonly encountered in patients with trauma, accounting for almost 90% of all spinal fractures. Thoracolumbar burst fractures comprise a high percentage of these traumatic fractures (45%), and approximately half of the patients with this injury pattern are neurologically intact. However, a debate over complication rates associated with operative versus nonoperative management of various thoracolumbar fracture morphologies is ongoing, particularly concerning those patients presenting without a neurological deficit. A MEDLINE search for pertinent literature published between 1966 and December 2013 was conducted by 2 authors (G.G. and R.D.), who used 2 broad search terms to maximize the initial pool of manuscripts for screening. These terms were "operative lumbar spine adverse events" and "nonoperative lumbar spine adverse events." In an advanced MEDLINE search of the term "operative lumbar spine adverse events" on January 8, 2014, 1459 results were obtained. In a search of "nonoperative lumbar spine adverse events," 150 results were obtained. After a review of all abstracts for relevance to traumatic thoracolumbar spinal injuries, 62 abstracts were reviewed for the "operative" group and 21 abstracts were reviewed for the "nonoperative" group. A total of 14 manuscripts that met inclusion criteria for the operative group and 5 manuscripts that met criteria for the nonoperative group were included. There were a total of 919 and 436 patients in the operative and nonoperative treatment groups, respectively. There were no statistically significant differences between the groups with respect to age, sex, and length of stay. The mean ages were 43.17 years in the operative and 34.68 years in the nonoperative groups. The majority of patients in both groups were Frankel Grade E (342 and 319 in operative and nonoperative groups, respectively). Among the studies that reported the data, the mean length of stay was 14 days in the operative group and 20.75 in the nonoperative group. The incidence of all complications in the operative and nonoperative groups was 300 (32.6%) and 21 (4.8%), respectively (p = 0.1065). There was no significant difference between the 2 groups with respect to the incidence of pulmonary, thromboembolic, cardiac, and gastrointestinal complications. However, the incidence of infections (pneumonia, urinary tract infection, wound infection, and sepsis) was significantly higher in the operative group (p = 0.000875). The incidence of instrumentation failure and need for revision surgery was 4.35% (40 of 919), a significant morbidity, and an event unique to the operative category (p = 0.00396). Due to the limited number of high-quality studies, conclusions related to complication rates of operative and nonoperative management of thoracolumbar traumatic injuries cannot be definitively made. Further prospective, randomized studies of operative versus nonoperative management of thoracolumbar and lumbar spine trauma, with standardized definitions of complications and matched patient cohorts, will aid in properly defining the risk-benefit ratio of surgery for thoracolumbar spine fractures.

A review of pediatric lumbar spine trauma.

Pediatric spine fractures constitute 1%-3% of all pediatric fractures. Anywhere from 20% to 60% of these fractures occur in the thoracic or lumbar spine, with the lumbar region being more affected in older children. Younger children tend to have a higher proportion of cervical injuries. The pediatric spine differs in many ways from the adult spine, which can lead to increased ligamentous injuries without bone fractures. The authors discuss and review pediatric lumbar trauma, specifically focusing on epidemiology, radiographic findings, types and mechanisms of lumbar spine injury, treatment, and outcomes.

Mature Teratoma of the Filum Terminale in the Elderly, Incidentally Diagnosed after an Unmyelinated Lumbar Spine Trauma

Introduction: Spinal teratoma is an extremely rare entity as it represents 0.10-0.60% of all spinal tumors. It is mainly diagnosed during the first two decades of life and can be associated with spinal dysraphism. Aim: To present a case of an asymptomatic mature teratoma of filum terminale, incidentally diagnosed in an elderly patient admitted to the Neurosurgery Department for multiple traumas after falling from 3 meters height. Case description: A 76 year-old patient was admitted in the 2nd Neurosurgery Department, “Prof. Dr. N. Oblu” Emergency Clinical Hospital, Iasi with multiple traumas after falling from 3 meters height. The patient presented bilateral paresthesia of lower limbs and urinary incontinence. Radiography of the dorsal-lumbar spine column in emergency highlighted a dorsal - lumbar fracture (D12-L1) with medullar compression. MRI examination revealed a neoformation of filum terminale that filled almost the entire spinal canal, which had a composite, fatty and fluid structure, corresponding to L2-L4 and compressing the medullary cone. The neurosurgical decision was the excision of the entire neoformation. The histopathological examination of excised pieces revealed the presence of adipose tissue mixed together with striated and smooth muscle fibers, small and large cysts lined by various epithelia ranging from malpighian keratinized multilayered to simple ciliated columnar epithelium. No immature or malignant cells were identified and therefore the diagnosis was mature teratoma of filum terminale. The evolution of the patient was favorable with the remission of the neurological deficit. Conclusions: Our patient is one of the oldest patients diagnosed up to date with a mature teratoma of filum terminale. Moreover, the location of neoformation at the lumbar (L2-L4) level is extremely rare. This case also highlights the fact that this mature teratoma was discovered by chance, when the patient came to the Neurosurgery Department for a spinal injury due to a falling from a tree.

Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU

Because of a lack of evidence, the appropriate timing of surgical stabilization of thoracic and lumbar spine injuries in severely injured patients is still controversial. Data of a large international trauma register were analyzed to investigate the medical care situation of unstable spinal column fractures in patients with multiple injuries, so as to examine the outcome related to timing of surgical stabilization. Data sets of the Trauma Registry of German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (1993-2010) were analyzed. The Trauma Registry of DGU is a prospective, multicenter register that provides information on severely injured patients. All patients with an Injury Severity Score (ISS) of 16 or greater caused by blunt trauma, subsequent treatment of 7 days or more, 16 years or older, and thoracic or lumbar spine injuries (spine Abbreviated Injury Scale [AIS] score ≥ 2) were included in our analysis. Patients with relevant spine injuries classified as having a spine AIS score of 3 or greater were further analyzed in terms of whether they got early (<72 hours) or late (>72 hours) surgical treatment due to unstable spinal column fractures. Of 24,974 patients, 8,994 (36.0%) had documented spinal injuries (spine AIS score ≥ 2). A total of 1,309 patients who sustained relevant thoracic spine injuries (spine AIS score ≥ 3) and 994 patients who experienced lumbar spine trauma and classified as having spine AIS score of 3 or greater were more precisely analyzed. Of these, 68.2% and 71.0%, respectively, received an early thoracic or lumbar spine fixation. With an increase in spinal injury severity, an increase in early stabilization in the thoracic and lumbar spine was seen. In the group of patients with early surgical stabilization, significantly shorter hospital stays, shorter intensive care unit stays, fewer days on mechanical ventilation, and lower rates of sepsis were seen. In the case that additional body regions were affected, for example, when patients were critically ill, a delayed spinal stabilization was more often performed. A spinal stabilization at an early stage (<72 hours) is presumed to be beneficial. Although some patients may require delay due to necessary medical improvement, every reasonable effort should be made to treat patients with instable spinal column fractures as soon as possible. If an early surgical treatment is feasible, severely injured patients may benefit from a shorter period of hospital treatment and a lower rate of complications. Therapeutic study, level III.

Retrospective evaluation of the validity of the Thoracolumbar Injury Classification System in 458 consecutively treated patients

Background contextThe Thoracolumbar Injury Classification System (TLICS) system has been developed to improve injury classification and guide surgical decision-making, yet validation of this new system remains sparse. PurposeThis study evaluates the use of the TLICS in a large, consecutive series of patients. Study design/settingThis is a retrospective case series. Patient sampleA total of 458 patients treated for thoracic or lumbar spine trauma between 2000 and 2010 at a single, tertiary medical center were included in this study. Outcome measuresAmerican Spinal Injury Association (ASIA) status and crossover from conservative to surgical treatment were measured. MethodsClinical and radiological data were evaluated, classifying the injuries by ASIA status, the Magerl/AO classification, and the TLICS system. ResultsA total of 310 patients (67.6%) was treated conservatively (group 1) and 148 patients (32.3%) were surgically (group 2) treated. All patients in group 1 were ASIA E, except one (ASIA C). In this group, 305 patients (98%) had an AO type A fracture. The TLICS score ranged from 1 to 7 (mean 1.53, median 1). A total of 307/310 (99%) patients matched TLICS treatment recommendation (TLICS≤4), except three with distractive injuries (TLICS 7) initially misdiagnosed. Nine patients (2.9%) were converted to surgical management. In group 2, 105 (70.9%) were ASIA E, whereas 43 (29%) had neurological deficits (ASIA A-D). One hundred and three patients (69.5%) were classified as AO type A, 36 (24.3%) as type B, and 9 (6%) as type C. The TLICS score ranged from 2 to 10 (mean 4.29, median of 2). Sixty-nine patients (46.6%) matched the TLICS recommendation; all discordant patients (53.4%) were treated for stable burst fractures (TLICS=2). No neurological complications occurred in either group. ConclusionsThe TLICS recommendation matched treatment in 307/310 patients (99%) in the conservative group. However, in the surgical group, 53.4% of patients did not match TLICS recommendations, all were burst fractures without neurological injury (TLICS=2). The TLICS system can be used to effectively classify thoracolumbar injuries and guide conservative treatment. Inconsistencies, however, remain in the treatment thoracolumbar burst fractures.

The precision, accuracy and validity of detecting posterior ligamentous complex injuries of the thoracic and lumbar spine: a critical appraisal of the literature.

The diagnostic assessment and prognostic value of the posterior ligamentous complex (PLC) remains a controversial topic in the management of patients with thoracolumbar spinal injury. The purpose of this review was to critically appraise the literature and present an overview of the: (1) precision, (2) accuracy, and (3) validity of detecting PLC injuries in patients with thoracic and lumbar spine trauma. Studies evaluating the precision, accuracy and/or validity of detecting and managing PLC injuries in patients with thoracic and/or lumbar spine injuries were searched through the Medline database (1966 to September 2011). References were retrieved and evaluated individually and independently by two authors. Twenty-one eligible studies were identified. Few studies reported the use of countermeasures for sampling and measurement bias. In nine agreement studies, the PLC was assessed in various ways, ranging from use of booklets to a complete set of diagnostic imaging. Inter-rater and intra-rater kappa values ranged from 0.188 to 0.915 and 0.455 to 0.840, respectively. In nine accuracy studies, magnetic resonance (MR) imaging was most often (n = 6) compared with intra-operative findings. In general, MR imaging tended to demonstrate relatively high negative predictive values and relatively low positive predictive values for PLC injuries. A wide variety of methods have been applied in the evaluation of precision and accuracy of PLC injury detection, leaving spinal surgeons with a multitude of variable results. There is scant clinical evidence demonstrating the true prognostic value of detected PLC injuries in patients with thoracic and lumbar spine injuries. We recommend the conduct of longitudinal clinical follow-up studies on those cases assessed for precision and/or accuracy of PLC injuries.