The aim of this study is to determine evidence-based guidelines on functional outcomes following common thoracolumbar injuries using a synthesis of systematic literature reviews and consensus expert opinion

A questionnaire was created comprising five cases representative of common thoracolumbar injuries (a thoracic compression fracture, a flexion distraction injury and burst fractures each with varied location, patient demographics and treatment strategies). For each scenario five questions about expected functional outcomes were posed. Questionnaires were distributed to the Spine Trauma Study Group. Responses were combined with available data from a systematic review of the same injuries and outcomes to create consensus evidence based guidelines.

The survey was completed by 31 (57%) of 53 surgeons representing 20 centres across North America. The systematic reviews identified 49 appropriate studies. One year following a L1 burst fracture, a heavy laborer, treated with protective mobilization (cast or brace) has a 40% chance of being pain free, 70% chance of regaining pre-injury range of motion, can expect to be re-employed within 4–6 months and be able to participate in high impact exercise and contact sport with no or minimal limitation. Length of inpatient stay averages 4–5 days. One year following posterior short segment stabilization of a L1 bust fracture in a college football player, there is an expected 45% chance of being pain free and 55% chance of regaining pre-injury ROM. While an ultimate return to high impact exercise and contact sports is anticipated, 32% of experts expect the injury to end a college football career.

Results for the other trauma scenarios are included.

This combination of literature and expert opinion represents the best available evidence on functional prognosis after thoracolumbar trauma. By providing consistent, accurate information surgeons and other care path providers will help patients develop realistic expectations, which may shape and improve their ultimate outcome.

Purpose: Multiple studies have described the general injuries associated with mountain biking. However, no detailed assessment of mountain biking associated spinal column fractures and spinal cord injuries (SCI) has previously been reported. The purpose of this study is to describe the patient demographics, injuries, mechanisms, treatments, outcomes and resource requirements associated with spine injuries sustained while mountain biking.

Method: Patients who were injured while mountain biking, and presented to a provincial spine referral centre between 1995 and 2007 inclusive, with SCI and/ or spine fracture were included. A chart review was performed to obtain demographic data, and details of the injury, treatment, outcome and resource requirements.

Results: 102 men and 5 women were identified for inclusion. The mean age at injury was 32.7 years 95%CI[30.6,35.0]. 79 patients (73.8%) sustained cervical injuries, while the remainder sustained thoracic or lumbar injuries. 43 patients (40.2%) sustained a SCI. Of those with cord injuries, 18(41.9%) were ASIA A, 5(11.6%) were ASIA B, 10(23.3%) ASIA C, and 10(23.3%) ASIA D. 67 patients (62.6%) required surgical treatment. The mean length of stay in an acute hospital bed was 16.9 days 95%CI[13.1,30.0]. 33 patients (30.8%) required ICU care, and 31 patients (29.0%) required inpatient rehabilitation. Of the 43 patients (39.6%) who presented with SCI, 14(32.5%) improved by one ASIA category, and 1 (2.0%) improved by two ASIA categories. Two patients remained ventilator-dependent at discharge.

Conclusion: Spine fractures and SCI due to mountain biking accidents typically affect young, male, recreational riders. The medical, personal, and societal costs of these injuries are high. Injury prevention should remain a primary goal, and further research is necessary to explore the utility of educational programs, and the impact of helmets and other protective gear on spine injuries sustained while mountain biking.

Purpose: To determine whether neural axis level of injury (SCI, CMI, or CEI) is related to motor improvement, as defined by the International Standards for Neurological Classification of Spinal Cord Injury motor score (MS), in patients with a thoracolumbar (T11-L3) spine injury.

Method: Fifty-three patients who sustained a neurological deficit secondary to a thoracolumbar spinal injury between 1995–2003 had injury details and MS collected prospectively. An independent evaluation determined the follow-up MS and SF-36 generic health-related quality of life (HrQOL) at a mean of 6.6 (SD 2.5) years post-injury. All patients had an MRI reviewed by a spine surgeon and neuroradiologist to determine the location of their conus medullaris and precise level of neural axis injury.

Results: Nineteen patients (37%) had SCI, 20 (39%) had CMI, and 12 (24%) had CEI, while two could not be classified. Patients with SCI improved their MS by an average 7.0 motor points (SD 9.8); CMI improved 11.9 (SD 11.8); and CEI improved 16.8 (SD 16.0). This trend did not achieve statistical significance (p=0.09). Multivariate analyses demonstrated that initial MS had a significant interaction with neural axis level of injury with respect to the primary outcome. Specifically, CEI showed the greatest improvement in MS only when the initial MS was less than 75. Absence of initial anal sensation, a fracture-dislocation injury type and increasing time to surgery were all statistically associated with less improvement in MS. The mean follow-up SF-36 physical component score (PCS) was 37.3 (SD 10.1) and the mean mental component score (MCS) was 51.4 (SD 11.8). There was no significant difference in mean PCS and MCS for varying levels of neural axis injury.

Conclusion: Patients with a CEI demonstrated the most improvement in MS, while absent anal sensation, a fracture-dislocation, and long delay to surgery were poor prognostic indicators for motor recovery. The HrQOL outcomes did not vary with neural axis level of injury. The results of this study assist in determining a prognosis for patients that sustain these common injuries. Future research should focus on how specific pre- and peri-operative variables affect outcomes in patients with neurological deficits secondary to thoracolumbar injuries.

Purpose: To quantify how well the physical examination of the shoulder predicts patient-reported functional outcome in a cohort of patients with previous proximal humerus fractures.

Method: Potential subjects were identified from a recent study cohort of proximal humerus fracture patients treated within the past six years. The cohort consisted of all fracture types and treatment modalities. Participants underwent a focused physical examination of their injured shoulder containing the components of the Constant-Murley shoulder score: range of motion for forward flexion, abduction, internal rotation, external rotation, and abduction strength measured by an IsoBex muscle strength analyzer. Participants also completed the following patient-reported functional outcome questionnaires: Disabilities of Arm, Shoulder, Hand (DASH), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), and Oxford Shoulder Score (OSS). Forward- and backward-stepwise linear regression was used to assess the relationship between the functional outcomes and the physical exam measurements.

Results: Thirty-one subjects with a mean age of 70 ± 8 years participated. Sixteen patients were previously treated with ORIF and 15 were treated with sling immobilization. The mean physical examination measures were: flexion 117° ± 31°, abduction 117° ± 37°, internal rotation 7° ± 2°, external rotation 7° ± 4°, and strength 6 ± 5 Newtons. The mean functional outcome scores were: DASH 21 ± 19, ASES 82 ± 17, SST 8 ± 3, and Oxford 20 ± 8. Using linear regression, adjusted R-squared statistics suggest components of the physical exam can explain 38% of the Oxford, 50% of the DASH, 58% of the SST, and 70% of the ASES variance. Abduction strength was a significant predictor for all functional outcomes. Combinations of flexion, abduction, or internal rotation were also significant predictors depending on the outcome instrument being modeled.

Conclusion: Physical exam of the shoulder accounts for differing amounts of patient-reported functional outcome variance. Abduction strength is the most consistent predictor of functional outcome within this cohort of proximal humerus fracture patients.

Purpose: Prospective Observational Population Study to describe the incidence, demographics and pattern of spinal cord injury in British Columbia, Canada, for 10 years to 2004.

Method: Systematic analysis of prospectively collected spine registry data (Vertebase) at Vancouver General Hospital, B.C., Canada from 1995–2004.

Results: During the 10-year study period the 938 patients were admitted with a traumatic spinal cord injury. The Annual Population-Standardized Incidences ranged from 19.94 to 27.27 per million, with a median incidence of 23.34/million and with no significant change over the study period. The mean age was 39.7 years (34.73 in 1995 and 42.1 in 2004, p< 0.05) with a range of 16–92 years. 79.74 % were males. 48.2% of patients were AISA A on admission, of which 48% were quadraparetic. The most common levels of spinal cord injury were C5 (17.3%), C6 (10%), T1 (9.4%), T12 (5.8%). The Mean ASIA score was 50.22 with a range from 0–100. 19.8% of patients had a GCS£13. The mean ISS was 26.02, range of 0 – 75. Motor vehicle collisions and falls were responsible for 59% and 30% of admissions respectively. Mean length of in-hospital stay was 34 days, ranging from 1 – 275 days. In hospital mortality rate was 2.9%. ASIA Grade, Total Motor Score and anatomical level of injury all correlated directly with Length of stay (p< 0.0001).

Conclusion: Acute Traumatic Spinal Cord Injury remains a major cause of significant morbidity among young males. The incidence appears to be increasing in the elderly. Modern multidisciplinary care has greatly reduced the associated acute mortality. Despite multiple prevention strategies the Annual Population-Standardized Incidence remained unchanged over the study period.