The purpose of this study was to evaluate and compare the effect of short segment pedicle screw instrumentation and an intermediate screw (SSPI+IS) on the radiological outcome of type A thoracolumbar fractures, as judged by the load-sharing classification, percentage canal area reduction and remodelling. . We retrospectively evaluated 39 patients who had undergone hyperlordotic SSPI+IS for an AO-Magerl Type-A thoracolumbar fracture. Their mean age was 35.1 (16 to 60) and the mean follow-up was 22.9 months (12 to 36). There were 26 men and 13 women in the study group. In total, 18 patients had a load-sharing classification score of seven and 21 a score of six. All radiographs and CT scans were evaluated for sagittal index, anterior body height compression (%ABC), spinal canal area and encroachment. There were no significant differences between the low and high score groups with respect to age, duration of follow-up, pre-operative sagittal index or pre-operative anterior body height compression (p = 0.217, 0.104, 0.104, and 0.109 respectively). The mean pre-operative sagittal index was 19.6° (12° to 28°) which was corrected to -1.8° (-5° to 3°) post-operatively and 2.4° (0° to 8°) at final follow-up (p = 0.835 for sagittal deformity). No patient needed revision for loss of correction or failure of instrumentation. Hyperlordotic reduction and short segment pedicle screw instrumentation and an intermediate screw is a safe and effective method of treating burst fractures of the thoracolumbar spine. It gives excellent radiological results with a very low rate of failure regardless of whether the fractures have a high or low load-sharing classification score. Cite this article: Bone Joint J 2014;96-B:541–7

Background context: Stable thoracolumbar spinal fracture is a common injury, yet there remains a relative lack of evidence that would allow reliable prediction of outcome. Variation in outcome in stable thoracolumbar spine fracture without neurological deficit could not be explained by the assessment made from x-rays and CT imaging alone, which measures mainly the bony injury severity. So far, no good classification system has been developed to assess the severity of soft tissue injury (disc). Objectives: To measure short-term outcome of stable thoracolumbar fracture and analyse aspects of injury severity for their ability to predict outcome. To develop a new disc injury severity grading system in thoracolumbar spine fractures. Study design: Prospective observational. Patient sample: 44 patients with stable fractures between T11 and L5 vertebra with no neurological deficit and treated conservatively were selected. Methods: All had plain x-rays, CT and MRI scans post-injury and at one year post-injury (except CT). Bony injury severity was scored on a seven-point ordinal scale based on (a) communication, (b) apposition and (c) kyphosis. Disc injury severity was scored by the newly developed six-point ordinal scale (none to severe) based on the following variables: (a) Herniation of the disc, (b) Indentation of the end plate, (c) Change in height and (d) Change in signal. Outcome was assessed at one to two years from injury. The following outcome measures were collected: (A) Five domains of pain symptoms – intensity, duration, bothersome, interference and satisfaction. (B) Five domains of function – Physical Component Summary (PSC) measure, Mental Component Summary (MSC) measure, Oswestry disability score, return to pre-injury level of overall activities and return to employment. Non-parametric correlation coefficients were calculated between outcome variables and other variables to look for the predictors of outcome. Stepwise linear regression analysis was performed to compare the predictive values and to look at what proportion of outcome is predicted by different predictors. Results: According to AO classification, the fractures were A1, A2, A3 and B1. The Spearman correlation coefficients between outcome and injury severity were consistently higher with disc injury severity than bony. For the outcome of pain intensity, the correlation coefficients for disc and bone injury severity respectively were:.63 (p < .0001) and.28 (NS-not significant). Similarly for SF36 PSC were: .41 (p < .01) and.25 (NS). The predictive value of pain at F < .01 was 29% for disc injury severity and all other variable were not significant and excluded. At F < .05, the predictive value of disc injury severity (29%) increased further by 9%, 8% and 6% by addition of variable “Patient’s pre-injury SF36 MSC”, “Legal and Compensation issues pending” and “Physical demand of job” respectively. The predictive value of function at F < .01 was 16% for disc injury severity and it increased to 31% by the addition of “physical demand of the job” variable. At F < 0.05 the predictive value further increased by 5% by addition of variable “Legal and Compensation issues pending”. All other variables were not significant. Conclusions: A new grading system of disc injury severity was developed and it showed good predictive value for pain and functional outcome. Disc injury severity has a better predictive value for short term outcome than bony injury severity in stable thoracolumbar fractures. In the spectrum of injuries studies, the AO classification and the degree of kyphosis provided no prediction of outcome

Stable thoracolumbar fracture is a common injury. The factors that determine its outcome are unclear. Aspects of injury severity were analysed for their ability to predict outcome by controlling other outcome-affecting factors (patient's pre-injury health status, legal aspects, associated injuries, etc.). No reliable disc injury severity grading system was available and therefore a new system was developed. A prospective observational study of 44 conservatively treated patients with stable fractures between T11 and L5 was conducted. Bony injury severity was scored based on comminution, apposition and kyphosis parameters. Disc injury severity was scored by the new scale based on variables – Herniation, Indentation, Height decrease and Signal change – seen in MRI. Ten outcome domains (five domains of pain and function each) were assessed at 1 to 2 years from injury. The data was analysed by non-parametric correlation and stepwise-linear regression analysis to assess the predictive value of different variables (patient factors, injury factors and social factor) to outcome. The correlation coefficients between injury severity and outcome were consistently higher with disc injury severity than bony. Disc injury severity showed highest predictive value for both pain (29%) and functional (16%) outcomes, whereas the bony injury severity parameters (kyphosis, etc.) and the posterior ligament injury severity provided no prediction of outcome. According to AO classification, the fractures were A1, A2, A3 and B1; in this spectrum of injuries, the AO classification had no prediction of outcome. The disc injury score also had a good predictive value for final disc degeneration. Disc injury severity should be gauged in advising prognosis and treatment. The new disc injury severity grading system showed good construct validity

Study Design/Objectives: A pilot study to predict thoracolumbar kyphosis progression secondary to fracture in non-operatively treated patients. Summary of Background Data: Progressive saggital plane deformity can cause persistent pain after thoracolumbar vertebral fractures. Little data exists to suggest at what interval after the index injury the patient attains a low risk of developing further angular deformity in non-operatively treated patients. Methods: Supine and erect radiographs were assessed and the degree of fracture kyphosis was determined using an Oxford Cobbometer. The fracture kyphosis was recorded for each follow up appointment along with time after the fracture. A time/data analysis was performed using the Blyth-Still-Casella exact interval. Results: This study included 22 patients (13 male, 9 female) with average age 67.2 years (range, 14–87 years). The average length of follow up was 11.5 months (range, 5.3–19.9 months) and the average number of radiographs taken within this period was 4 (range, 2–6). The change in fracture kyphosis was plotted against time following fracture. Based on 15 patients with data extending to 200 days follow up, it was observed that the rate of change in fracture kyphosis between two time points of 100 and 150 days predicted the trend in kyphosis progression until the end of follow up in 14 out of the 15 patients. This observed rate of 14/15 (0.93) has a 95% confidence interval of 0.7 to 0.99 (Blyth-Still-Casella exact interval). Conclusions: The standing lateral radiograph of patients with conservatively treated thoracolumbar fractures at 3 and 4.5 months post injury can be used to predict fracture kyphosis progression. Using this protocol, patients can be safely discharged earlier from outpatient follow up reducing radiological exposure

We assessed narrowing of the spinal canal in 39 burst fractures and fracture-dislocations of thoracolumbar vertebrae treated by the AO Internal Spinal Fixator, using CT preoperatively and at various stages postoperatively. Computer-aided planimetry was used to measure the narrowing, and its restoration shortly after instrumentation, or at 15 months. The mean initial reduction of canal area was to 63.7% +/- 18.8% of normal; this was restored to a mean of 95.4% +/- 21.2% of normal when measured either soon after surgery or at 15 months (p < 0.001 for both groups). There was more improvement in cases assessed later. For fractures from D12 to L3, the mean canal area was restored to 99.4% of normal; but at L4 or L5 the mean restitution was to only 60.9% (p < 0.05). We found no correlation between preoperative loss of area and amount of restoration, or severity of neurological deficit. Nor was there any correlation between the delay before surgery and the improvement achieved. The mechanism of fracture reduction appears to be a combination of distraction ligamentotaxis and forced hyperextension.

Of a total of 905 patients with fracture or fracture-dislocation of the thoracolumbar spine admitted from 1969 to 1982, a neurological deficit was present in 334 (37%). All unstable injuries were initially treated by reduction and posterior fusion. In 79 of these patients, an anterolateral decompression was undertaken later because of persistent neurological deficit and radiographic demonstration of encroachment on the spinal canal. One patient died of pulmonary embolism; 78 were reviewed after a mean period of four years. Of these 78 patients 18 made a complete neurological recovery while 53 appeared to have benefited from the procedure; 25 remained unchanged. The best results were obtained in burst fractures at thoracolumbar and lumbar levels when a solitary detached fragment of a vertebral body had been displaced into the spinal canal. These results indicate that anterolateral decompression of the spinal canal should be considered, after careful evaluation, for certain injuries of the spine in which there is severe neural involvement

Introduction. The management of thoracolumbar burst fractures is controversial. The goal of our study was to evaluate whether the psychological factors or the late spinal deformities influence outcome and in particular quality of life following surgical treatment of burst fractures of the thoracolumbar spine. Material and methods. In a retrospective analysis, we evaluated outcome in 45 patients in whom burst fractures of the thoracolumbar spine without neurological deficits were surgically treated between April 2001 and November 2004. For this purpose, patient charts, surgery reports and x-ray images were analyzed consecutively. 29 patients could be examined physically and the outcome could be evaluated with VAS spine core, quality of life according to short-form 36 (SF36) and Beck Depression Inventory (BDI) with a minimum follow up of 30 months. Results. Mean VAS spine score was 60±26. Neither VAS spine score, nor quality of life results correlated with the following radiological findings: vertebral body angle, sagittal index and height of cranial disc space of the vertebra. Beck Depression Inventory (BDI) correlated with SF-36 score and VAS spine score (p< 0.05). Patients who were depressed showed significantly worse results in relation to the VAS spine score and the SF36 score (p< 0.01). Conclusion. For the first time, we could show, that psychological factors have high influence on functional outcome and health related quality of life in operative treated thoracolumbar burst fracture independent of x-ray findings. Therefore, we recommend inclusion of psychological components in the treatment and outcome-evaluation of the thoracolumbar burst fracture in future

The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of ‘missed injury’.

We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk.

Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury.

Many authors recommend surgery to remove retropulsed bone fragments from the canal in burst fractures to 'decompress' the spinal canal. We believe, however, that neurological damage occurs at the moment of injury when the anatomy is most distorted, and is not due to impingement in the resting positions observed afterwards. We studied 20 consecutive patients admitted to our spinal injuries unit over a two-year period with a T12 or L1 burst fracture. There was no correlation between bony or canal disruption and the degree of neurological compromise sustained but there was a significant correlation between the energy of the injury (as gauged by the Injury Severity Score) and the neurological status (p < 0.001). This suggests that neurological injury occurs at the time of trauma rather than being a result of pressure from fragments in the canal afterwards and questions the need to operate simply to remove these fragments.

In 139 patients with burst fractures of the thoracic, thoracolumbar or lumbar spine, the least sagittal diameter of the spinal canal at the level of injury was measured by computerised tomography. By multiple logistic regression we investigated the joint correlation of the level of the burst fracture and the percentage of spinal canal stenosis with the probability of an associated neurological deficit. There was a very significant correlation between neurological deficit and the percentage of spinal canal stenosis; the higher the level of injury the greater was the probability. The severity of neurological deficit could not be predicted.

Study design. Retrospective study. Objectives. To identify patient outcomes, in particular employment, >5-years following traumatic thoracolumbar fracture. Methods. 235 patients between the ages of 18–65 were identified from the hospital radiology database having sustained a traumatic thoracolumbar fracture on CT or MRI between 01/01/2013 and 31/01/2017. Questionnaires were sent out via post and available emails, with a reminder letter and phone calls. Retrospective data was gathered about employment status pre-fracture and >5-years post injury. Results. 26 patients had died at follow up leaving 209 patients. 108 (52%) were treated surgically and 101 (48%) conservatively. 106 replies were received with 85 (80%) opting in and 21 (20%) opting out. 68 (80%) patients completed the full questionnaire with 17 (20%) filling out a shortened questionnaire via a phone conversation. 52 (61%) patients underwent surgery and 33 (39%) were treated conservatively. The average follow up was 8 years. Prior to injury 66 (78%) were employed and 19 (22%) unemployed (of which 6 were full time students and 8 were retired). 49 (74%) of the previously employed patients returned to work at follow up with 35 (53%) working the same or increased hours. Regarding employment, there was no significant difference between surgically and conservatively treated patients (P=0.355) or the classification of the fracture (P=0.303). 16 (19%) patients reported back pain prior to their injury whilst 69 (81%) did not. There were 58 (68%) cases of new pain at follow up with the most affected area being the lumbar region in 43 (51%) patients. 32 (38%) patients reported neurological deficit post injury: 19 with subjective symptoms, 9 with objective symptoms and 4 suffered paralysis. Conclusion. >5-years following a traumatic thoracolumbar fracture most individuals return to employment. There was no significant difference between the severity of the fracture or how patients are treated on their employment outcomes

Objectives. This presentation discusses the experience at our Centre with treating traumatic thoracolumbar fractures using percutaneous pedicle screw fixation and also looks at clinical and radiological outcomes as well as complications. Design. This is a retrospective study reviewing all cases performed between Jan 2013 and June 2019. Subjects. In our study there were 257 patients in total, of which there were 123 males and 134 females aged between 17 and 70. Methods. We reviewed the case notes and imaging retrospectively to obtain the relevant data. Results. A total of 257 patients were included, 123 males and 134 females; the mean age was 47.6 years. The majority of injuries were from fall from significant height. In 98 cases the fracture involved a thoracic vertebra and in 159 cases a lumbar vertebra. Percutaneous pedicle screw fixation was performed either one level above and below fracture or Two levels above and below the fracture depending upon the level of injury. Forty two cases were treated with additional short pedicle screws at the level of fracture. More than 15% (39) of patients presented with a neurological deficit on admission and more than 80% (32) of those showed post-operative improvement in their neurology as per Frankel Grading system. The mean Operative time was 117minutes +− 45, and mean length of hospital stay was 7.2 +− 3.8 days, with significant improvement in Visual analogue score. Percutaneous fixation achieved a satisfactory improvement in radiological parameters including sagittal Cobb angle (SCA) post-operatively in all patients. The vast majority of patients achieved a good functional outcome according to modified Macnab criteria. Follow up was for a maximum of two years, with relevant imaging at each stage. Ten (3.8%) patients had wound infection with three patients requiring wound debridement. Four patients had upper level screws pulled out and in Four cases one screw was misplaced. All eight had revision surgery. Conclusions. Percutaneous pedicle screw fixation is a safe surgical option with comparable outcomes to open surgery and a potential reduction in perioperative morbidity. Percutaneous pedicle screw fixation is the primary surgical technique to treat traumatic thoracolumbar fractures at our Centre. There were no major complications in our series, with good functional outcome following surgery

Thoracolumbar injury classification systems are not used or researched extensively in paediatric population yet. This systematic review aims to explore the validity and reliability of the two main thoracolumbar injury classification systems in the paediatric population (age ≤ 18). It also aims to explore the transferability of adult classification systems to paediatrics. The Thoracolumbar Injury Classification System (TLICS) published in 2005 and the AO Spine published in 2013 were assessed in this paper because they both provide guidance for the assessment of the severity of an injury and recommend management strategies. A literature search was conducted on the following databases: Medline, EMBASE, Ovid during the period November 2020 to December 2020 for studies looking at the reliability and validity of the TLICS and AO Spine classification systems in paediatric population. Data on validity (to what extent TLICS/ AO Spine recommended treatment matched the actual treatment) and reliability (inter-rater and intra-rater reliability) was extracted. There is an “almost perfect validity” for TLICS. There is a “strong association” between the validity of TLICS and AO Spine. The intra-rater reliability is “moderate” for TLICS and “substantial” for AO Spine. The intra-rater reliability is “substantial” for TLICS and “almost perfect” for AO Spine. The six studies show a good overall validity and reliability for the application of TLICS and AO Spine in pediatric thoracolumbar fractures. However, implication of treatment and anatomical differences of the growing spine should be explored in detail. Therefore, AO Spine can be used in absence of any other classification system for paediatrics

Introduction:. Most of the published papers on AI based diagnosis have focused on the algorithm's diagnostic performance in a ‘binary’ setting (i.e. disease vs no disease). However, no study evaluated the actual value for the clinicians of an AI based approach in diagnostic. Detection of Traumatic thoracolumbar (TL) fractures is challenging on planar radiographs, resulting in significant rates of missed diagnoses (30-60%), thus constituting a field in which a performance improvement is needed. Aim of this study is therefore to evaluate the value provided by AI generated saliency maps (SM), i.e. the maps that highlight the AI identified region of interests. Methods:. An AI model aimed at identifying TL fractures on plain radiographs was trained and tested on 567 single vertebrae images. Three expert spine surgeons established the Ground Truth (GT) using CT and MRI to confirm the presence of the fracture. From the test set, 12 cases (6 with a GT of fracture and 6 with a GT of no fracture, associated with varying levels of algorithm confidence) were selected and the corresponding SMs were generated and shown to 7 independent evaluators with different grade of experience; the evaluators were requested to: (1) identify the presence or absence of a fracture before and after the saliency map was shown; (2) grade, with a score from 1 (low) to 6 (high) the pertinency (correlation between the map and the human diagnosis), and the utility (the perceived utility in confirming or not the initial diagnosis) of the SM. Furthermore, the usefulness of the SM was evaluated through the rate of correct change in diagnosis after the maps had been shown. Finally, the obtained scores were correlated with the algorithm confidence for the specific case. Results:. Of the selected maps, 8 had an agreement between the AI diagnosis and the GT, while in 4 the diagnosis was discordant (67% accuracy). The pertinency of the map was found higher when the AI diagnosis was the same as the GT and the human diagnosis (respectively p-value = .021 and <.000). A positive and significant correlation between the AI confidence score and the perceived utility (Spearman: 27%, p-value=.0-27) was found. Furthermore, evaluator with experience < 5 year found the maps more useful than the experts (z-score=2.004; p-value=.0455). Among the 84 evaluation we found 12 diagnostic errors in respect to the GT, 6 (50%) of which were reverted after the saliency map evaluation (z statistic = 1.25 and p-value = .21). Discussion:. The perceived utility of AI generated SM correlate with the model confidence in the diagnosis. This highlights the fact that to be considered helpful, the AI must provide not only the diagnosis but also the case specific confidence. Furthermore, the perceived utility was higher among less experienced users, but overall, the SM were useful in improving the human diagnostic accuracy. Therefore, in this setting, the AI enhanced approach provides value in improving the human performance

Study design: retrospective clinical study . Objective: To study radiological late results after posterior stabilization of thoracolumbar fractures with internal fixation. To know factors related with loss of correction and hardware failure. Summary of background data: The posterior approach using an internal fixator is a standard procedure for stabilizing the injured thoracolumbar spine. None of the surgical techniques used was able to maintain the corrected the kyphosis angle. Methods: Forty-five patients with thoracolumbar fractures were included in the study. The inclusion criterion was the presence of fracture through the T11-L3 vertebrae without neurologic compromise. The Load-sharing classification has been used for all patients to determine the fracture severity. Surgical techniques (short or long instrumentation) , preoperative and postoperative radiographs ( Cobb technique) and follow-up records of all patients were reviewed carefully from the time of surgery until final follow-up assessment. Results: 13 patients were treated using short-segment instrumentation (two disc spaces) and 32 patients with long-segment instrumentation (more than two disc spaces). The mean follow-up was 3.4 years (range 1 to 11 years). The mean preoperative Cobb angle was 16.1 degrees and after surgery the mean angle was 6.8° representing an average correction of 9.2 ° . At follow-up assessments the mean Cobb angle was 13.2° representing a loss of correction of 6.4°. Implant failure ( 5 loosening and 8 breakage) was seen in 28.8% of patients: 6/14 (42%) of patients receiving short instrumentation and 7/31 (22%) of patients with long instrumentation. Hardware failure was seen in 53.3% of patients with Cobb angle preoperative more than 20° and in 16.6% of patients with Cobb angle less than 20°. Conclusions: Radiological behaviour of thoracolumbar fractures treated with posterior instrumentation without anterior support was worse than expected. Hardware failure was related with Cobb angle fracture > 20°, postoperative correction superior than 10° and short pedicular instrumentation technique

Background: Thoraco-lumbar fractures without a neurological deficit are usually suitable for non-operative treatment. The main area of clinical interest is the deformity at the injured levels. The deformity may be evident at the time of presentation, though could be expected to progress in time. Objective: Accurate assessment of the temporal behaviour in the geometry of the injured segments in non-operatively treated thoracolumbar fractures with normal neurology. Materials: 102 patients with thoracolumbar fractures without a neurological deficit were treated non-operatively at our unit between June 2003 and May 2006. The mean age of our patient cohort was 46.9 yrs (16–90 yrs). Strict criteria were followed to determine suitability for non-operative treatment. Supine radiographs were performed at the initial assessment. Erect radiographs were performed when trunk control was achieved and at follow-up assessments thereafter. Methods: Quality Motion Analysis (QMA) software (Medical Metrics Inc, Houston, Tx) was used to measure rotational and translation changes between the end plates using a validated protocol. The radiographs were standardised for magnification and superimposed from different time points. Transformation matrices were used to track the changes. The AO classification was used to classify the fractures by 2 independent observers. Results: A median of 4 radiographs were analysed for each patient (range 2–9), at a mean follow-up of 5.6 mo (95% CI 4.1–7.1 mo). 92% of the cohort had sustained a 1 level injury. 76% of the injuries were between T12 and L2; 19% were in the thoracic spine. An inter-observer rating of 0.58 was obtained for the classification of the primary fracture type. The mean rotational change was −1.4855° ± 0.248° (95% CI: −0.994° to–1.976°). The mean anterior vertebral body height collapse was −4.3444° ± 0.6938 (95% CI: −2.695 to −5.724). The mean posterior vertebral height collapse was −0.7987 ± 0.259 (95% CI: −0.284 to −1.313). Conclusions: We report the use of QMA software to track changes in the vertebral body geometry accurately. This has implications on the clinical aspects of management of thoracolumbar fractures based to progression of deformity that could be explored in future studies

Introduction: Spinal fractures are associated with pain, disability, neurological dysfunction and mortality. Osteoporosis and risky leisure time activities are increasing in the population. New treatment options have been introduced. However, only a few international studies have reported its descriptive epidemiology. There are no clear consensuses regarding the choice of operative interventions versus non-operative treatment in patients with thoracolumbar fractures. Treatment is often based on local traditions, skills and experiences. The aim of this nationwide study is to analyse the incidence, the characteristics of the patients, the subsequent development, surgical incidence and mortality rate among hospitalized patients with thoracolumbar fractures in Sweden. Methods: All discharges between 1997 and 2000 with diagnoses of thoracic or lumbar vertebrae fracture according to ICD 10 classification were selected from the National Inpatient Register. Surgery in these patients was categorised by procedure codes indicating spine operations. In order to calculate the risk of patients dying, linkage was performed to the Swedish Death Register using the unique personal identification number. Results: We identified 13, 496 admissions during the study period. This corresponds to an incidence rate of 30 per 100, 000 person-years and the occurrence was stable during 1997 and 2001 for patients younger than 50 years but decreased for patients above 50 years. The incidence of spine surgery among all patients was 1.9 per 100, 000 person-years, ranging from 1.6 per 100, 000 inhabitants per year to 2.6 per 100, 000 in the different region of Sweden. The most common causes of the fracture were falls (53 %) followed by vehicle accidents (37%). Almost two thirds of the patients operated on were men (63 %) and two thirds had lumbar vertebral fractures (66 %). The median age of the patients operated on was 42 years. The median length of stay was eight days. Among those who was operated the 30 days case fatality rate was 0.7 %. Median age for death was 64 years. Operations were less common in women (OR 0.79). The number of patients operated on during the last study year 2001 was significantly increased (OR 1.29). The probability of being operated on was highest in the more urban and densely populated regions of Stockholm and southern Sweden. Discussion: This national study based study showed a stable cumulative incidence of thoracolumbar fractures over the year 1997–2000. However, the two last year of this study an increased incidence of operation was observed. A possible explanation of this finding could be the new percutaneus technique for verterbroplasty. We find it of most importance to further investigate the reasons behind the gender differences in surgical incidence in patients with vertebral fractures

Background: There is conflicting evidence of correlation between clinical outcome and severity of thoracolumbar spine fractures in neurologically intact patients. 1. Kalyan et al2 presented the results of their prospective study of thoracolumbar spinal fractures and concluded that the clinical outcome was consistently better predicted by the severity of disc injury than that of the bony fracture. They suggested that if severe disc injury was present, treatment of the disc injury may result in a better short term clinical outcome. The aim of this study was to detail the incidence and type of disc injury in patients with thoracolumbar spinal fractures with intact neurology. Methods: Retrospective analysis of a prospectively collected spinal injury database at a regional spinal injuries unit. Only patients with a thoracolumbar spinal fracture and intact neurology were included. Retrospective analysis of magnetic resonance imaging (MRI) findings. One hundred and thirty nine neurologically intact patients (89M:50F, mean age 36 years, range 15 – 77yrs) with a thoracolumbar (T11 –L5) spinal fracture were admitted to our spinal unit over the last 11 years (1994 – 2004). Patient data was collected prospectively onto a spinal injuries database. All of these patients had an MRI scan on admission. All types of thoracolumbar fracture were included in this study and the presence or absence of an associated disc injury was recorded retrospectively from the MRI study. The type of disc injury was also recorded. Results: The incidence of severe disc injury adjacent to a thoracolumbar spinal fracture in our cohort of patients was 43% (60 patients). Disc prolapse or extradural herniation was seen in 16 patients (11%). Intraosseous disc herniation into an adjacent vertebral body was seen in 20 patients (14%). Internal disc disruption was seen in 24 patients (17%). Disc injury was found at more than one level in 21 patients (15%). Conclusion: The incidence of severe disc injury in our study of neurologically intact patients with a thoracolumbar fracture was considerable (43%). Kalyan et al. 2. suggested that treatment directed at addressing the disc injury in these patients may promote earlier pain relief and also earlier return to pre-morbid activities. If this is the case, then the decision making regarding operative versus non-operative management, in a patient with a thoracolumbar fracture and intact neurology, should be based on the severity of the disc injury as well as the bony injury

Purpose: The purpose of this study was to analyse the results and morbidity of video-assisted minimally invasive thoracoctomy for anterior arthrodesis of thoracolumbar fractures treated with a two-stage procedure and to evaluate mid-term outcome. Material and methods: This retrospective series included 6 patients with an unstable thoracolumbar fracture who underwent surgery between November 1997 and June 2002. A two-stage procedure was used: posterior reduction osteosynthesis and anterior arthrodesis with a tricortico-cancellous graft via video-assisted minimally invasive thoracotomy. The cohort included six women and eighteen men, mean age 34.5 years. Fractures were located at: L1 (n=4), T12 (n=10), T11 (n=2). At initial assessment the Franckel classification was: A (n=3), B (n=1), C (n=1), D (n=3), 3 (n=18). Time between the posterior procedure and the anterior thoracotomy was 30.2 days (range 6–86). Postoperative results as well as the time to fusion were recorded. Mean follow-up was 21 months (range 6–45) for functional and radiological assessment. No patient was lost to follow-up. Results: Mean operative time was 188 min (range 80–240). Mean blood loss was 235 ml (range150–1000) with no intraoperative event requiring conversion to open thoracotomy. Mean duration of morphine administered postoperatively was 2.2 days, the same as for thoracic drainage. Residual pleural effusion was observed in one patient and residual pneumothorax in two; all resolved spontaneously. Mean hospital stay was 12 days (range 6–27). Twenty-five patients had achieved fusion at four months. One patient developed a radiological non-union which was asymptomatic at one year. At last follow-up, the Oswestry function score was 22.6% for the entire series, 18% for Franckel D or E patients (n=21) and 42% for Franckel A, B and C patients (n=5). Loss of angular correction of the spinal kyphosis and regional traumatic angulation between the postoperative films and the last follow-up films was 2 (mean). Discussion: This series of complementary anterior arthrodesis by video-assisted minimally invasive thoracotomy confirmed the minimally invasive nature of this approach in comparison with thoracophrenolaparotomy and its complications. At mid term, this technique has provided satisfactory functional and radiographic results. Applied for thoracolumbar fractures, this combined surgical option can limit intraoperative morbidity and assure good mid-term results

Introduction: Treatment of thoracolumbar fractures remains controversial. The treatment options are conservative management or operative treatment, either through a posterior or anterior approach. Surgery through an anterior approach provides excellent decompression through vertebrectomy and the ability to correct the deformity. Stabilisation with Moss cage and Kaneda device remains unproven. Methods and Results: This is a retrospective study of 55 consecutive patients with thoracolumbar fractures operated on between 1993–99. Indications for surgery were: neurological deficit, two or three column injury causing instability or significant kyphotic deformity . There were 34 male and 21 female patients, mean age 33 years old. Trauma was caused by a fall from a height, either due to accident (30 patients) or suicide attempt (5), RTAs (14), sporting injury (6). Other injuries included multiple level spinal fractures (9 patients), pelvic (5), calcaneal (3), talar (1) and malleolar (1) fractures. Surgery was performed on the next available list unless there was an indication for emergency intervention, (mean 5 days post injury, range 1–19). Post-operative hospital stay averaged 17 days (7–59). Forty-seven patients underwent an anterior procedure alone, whilst eight patients had combined anterior and posterior instrumentation and fusion. Mean operative time was 207 minutes (150–360) and blood loss 2670 ml (985– 7000). Nineteen patients (35% of all) had neurological deficit. Neurological status improved post-op in 85% of these patients, remained the same in nine per cent and there was a nerve root injury in one patient (revision case) which has almost recovered. Other complications included five chest infections, three UTIs, one incisional hernia, four implant problems and eight patients with thigh pain. Results were analysed according to return to work and the Oswestry Disability Score with a mean follow-up of three years. Thirty-eight patients (69%) returned to the same occupation held before the injury, 11 patients (20% ) had a lighter job and six patients ( 11% ) are not working with litigation going on. Oswestry Disability Score post-op was 24% (4%–72%). Conclusion: Compared to the natural history of conservatively treated thoracolumbar fractures, surgical treatment with anterior decompression and stabilisation with Moss cage and Kaneda device offers considerable advantages. It enables a thorough decompression and has the advantage of providing greater deformity correction than the traditional posterior approach while instrumenting fewer vertebrae, thus preserving spinal motion segments. Early mobilization of the patients is a major advantage

Purpose of study: There is a controversy in the surgical treatment of unstable thoracolumbar burst fractures scoring high on the Load Sharing Classification (LSC). We have been treating unstable thoracolumbar fractures with postero-lateral fusion using short segment instrumentation and in this study we investigated our complication rate. Methods and results: We retrospectively reviewed notes and radiographs of patients presenting with thoracolumbar burst fractures and stabilised with a short-segment instrumented postero-lateral fusion between 1998 and 2007. We identified 31 patients who had adequate documentation and radiographs. Twenty patients had a high (> =7) LSC score and none of these fixations failed. Overall early and late complication rate was low (one wound infection, one dehiscence and four unrelated infections), the one metalwork failure related to infection. Fifty-five percent of patients returned to full-time work. Approximately 50% of correction of kyphosis was lost but the average kyphosis at final follow-up was 11 degrees that we thought was acceptable. Conclusion: We concluded that treating unstable burst fractures with posterior instrumented fusion alone using a pedicle screw construct does not result in late instrumentation failure, high complication rate or unacceptable final deformity. Ethics approval: None. Interest Statement: None

Introduction and Objective. Up to 30% of thoracolumbar (TL) fractures are missed in the emergency room. Failure to identify these fractures can result in neurological injuries up to 51% of the casesthis article aimed to clarify the incidence and risk factors of traumatic fractures in China. The China National Fracture Study (CNFS. Obtaining sagittal and anteroposterior radiographs of the TL spine are the first diagnostic step when suspecting a traumatic injury. In most cases, CT and/or MRI are needed to confirm the diagnosis. These are time and resource consuming. Thus, reliably detecting vertebral fractures in simple radiographic projections would have a significant impact. We aim to develop and validate a deep learning tool capable of detecting TL fractures on lateral radiographs of the spine. The clinical implementation of this tool is anticipated to reduce the rate of missed vertebral fractures in emergency rooms. Materials and Methods. We collected sagittal radiographs, CT and MRI scans of the TL spine of 362 patients exhibiting traumatic vertebral fractures. Cases were excluded when CT and/or MRI where not available. The reference standard was set by an expert group of three spine surgeons who conjointly annotated (fracture/no-fracture and AO Classification) the sagittal radiographs of 171 cases. CT and/or MRI were used confirm the presence and type of the fracture in all cases. 302 cropped vertebral images were labelled “fracture” and 328 “no fracture”. After augmentation, this dataset was then used to train, validate, and test deep learning classifiers based on the ResNet18 and VGG16 architectures. To ensure that the model's prediction was based on the correct identification of the fracture zone, an Activation Map analysis was conducted. Results. Vertebras T12 to L2 were the most frequently involved, accounting for 48% of the fractures. Accuracies of 88% and 84% were obtained with ResNet18 and VGG16 respectively. The sensitivity was 89% with both architectures but ResNet18 had a significantly higher specificity (88%) compared to VGG16 (79%). The fracture zone used was precisely identified in 81% of the heatmaps. Conclusions. Our AI model can accurately identify anomalies suggestive of TL vertebral fractures in sagittal radiographs precisely identifying the fracture zone within the vertebral body

Introduction. In all traumatic injury there is a clear relationship between the structural tissue damage and resultant disability after recovery. There are no publications that compare significant thoracolumbar osseous injury to non specific soft tissue injury. Aim. To compare spinal outcome measures between patients with self reported back pain in the workplace perceived as injury to those having sustained structural injury in the form of an unstable thoracolumbar fracture requiring surgical stabilisation. Method. Two consecutive cohorts consisting of 23 patients with healed thoracolumbar fractures and 21 patients with a perception of work related injury were compared. Patient outcomes were measured using the Oswestry Disability Index (ODI), Low Back Outcome score (LBOS), Modified Somatic Perception (MSP) and Modified Zung Depression (MZD) indices. Results. 23 patients (8 females; 15 males) with spinal fractures (group 1), of average age 42 years were followed up for a mean of 41 months post trauma and compared to 21 patients (6 females; 15 males) with self reported back pain pursuing compensation claims, (group 2), of average age 47 years, mean time since perceived injury of 42 months. Both groups were comparable in terms of age and sex. The average ODI in group 1 was 28% (SD 18.5) compared to 52% (SD 17.1) in group 2 (P: 0.0003). Similarly, LBOS was 39.7 Vs 20.3 (P: 0.0003); MSP 4.3 Vs 9.65 (P: 0.03); and MZD 20.2 Vs 35.9 (P: 0.001) in groups 1 and 2 respectively. Conclusion. Despite high energy trauma and significant structural damage to the spine, post-traumatic patients had better spinal outcome scores in all measures (ODI, LBO, MSP, MZD). There is no ‘dose-response’ relationship to functional outcomes. In fact, the disability seems greater in the lower energy injury which is unique in trauma care

Introduction: Introduction of the minimal invasive surgery as a new concept in spinal surgery necessitated the need for implants that can be applied through minimal invasive approaches. One of the great challenges was the development of anterior minimal invasive vertebral replacement implants that are mechanically fit and easily applicable. Many studies were concerned with the early results of such implants but not yet the long-term or late ones. Methods: Between January 2003 and December 2003 we have operated 23 patients (13 males and 10 females) with traumatic thoracic or thoracolumbar fractures that were indicated for corpectomy. In addition to posterior transpedicular instrumentation, anterior thoracoscopically assisted corpectomy and reconstruction using a telescopic vertebral body replacement cage was done in all patients. Patients were operated either in one or two sittings. Preoperative complete clinical, neurological and radiological evaluation was done. Postoperatively, clinical and radiological outcomes were evaluated, including postoperative neurological improvement, ODI (Oswestry Disability Index) and fusion rate. The average follow up period was 4 years. Results: Fusion rate was 100% at the final follow up. The mean age was 52.5 years. 6 patients had preoperative neurological deficits varying from Frankel B to Frankel A that were improved postoperatively in 5 cases and not improved in one case. The average corpectomy time was 148 minutes (range 75–240 min.). The average ODI was 8.6 (range 0 – 31). Postoperative complications included wound healing problems in one patient, psoas abscess in one patient and pulmonary embolism in one patient. The average preoperative kyphosis (Cobb angle) was 22.43 that were improved to 7.28 degrees postoperatively, and it was 11.8 degrees at the final follow up. Considerable cage sinking (more than 5 mm) was detected in two cases. Conclusion: Vertebral body replacement cage that can be thoracoscopically applied is a good solution for ventral implants in cases of thoracolumbar fractures that required corpectomy. It showed good early as well as 4 years follow up results. Study Type: Prospective observational study

Purpose of the study: The treatment of thoracolumbar fractures has evolved over the last five years with cementoplasty percutaneous osteosynthesis in addition to the gold standard orthopaedic or surgical treatments. This percutaneous method preserves muscles and maintains reduction to healing. The purpose of this work was to evaluate our results in traumatology patients after five years experience, deducting our current indications. Material and methods: From February 2004 to February 2009, we included 60 patients with a type A or B2 thoracolumbar fracture free of neurological problems and who had more than 10° kyphosis. Reduction was achieved in hyperlordosis before the percutaneous procedure. In other cases we used open arthrodesis. This was a retrospective analysis of a consecutive monocentre series including 37 men and 23 women, mean age 37 years. The injury was L1 and T12 in the majority. Classification was A1 and A3 for the majority. Osteosynthesis was achieved with an aiming compass and radioscopy. A removable corset was used as needed. Reduction and position of the screws as well as need for a complementary anterior fixation were assessed on the postoperative scan. Clinically, follow-up measured pain and quality of life (VAS and Oswestry), radiographically, vertebral kyphosis. Results: Mean follow-up was 24 months. At last follow-up, the VAS was 15/100 and the Oswestry 16/100. Material was removed in ten patients. Early in our experience one patient developed neurological problems postoperatively requiring revision surgery. Postoperative vertebral kyphosis was stable at three months and was sustained at two years. Body healing was successful in all cases. There were no cases of material failure. Discussion: This is a reliable reproducible technique in the hands of a spinal surgeon. Material removal can be proposed about one year after implantation. After the age of 65 years, we favour cementoplasty. For others, we propose a sextant for A1, A2, A3 or B2 fractures with more than 15° vertebral kyphosis. This percutaneous material had major advantages for tumour surgery, for multiple injury patients and for traumatology (especially when a double approach is used). Conclusion: Percutaneous osteosynthesis of vertebral fractures is now the gold standard for well defined indications. Two therapeutic fundamentals are reduction on the operative table and preservation of the muscle stock. These satisfactory results should be confirmed after removal of the implants

The June 2023 Spine Roundup³⁶⁰ looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial.

Decision-making regarding operative versus non-operative treatment of patients with thoracolumbar burst fractures in the absence of neurological deficits is controversial, and evidence from trials is sparse. We present a systematic review and meta-analysis of randomised trials comparing operative treatment to non-operative treatment in the management of thoracolumbar burst fractures. With the assistance of a medical librarian, an electronic search of Medline Embase and Cochrane Central Register of Controlled trials was performed. Trials were included if they: were randomided, had radiologically confirmed thoracolumbar (T10-L3) burst fractures, had no neurological deficit, compared operative and non-operative management (regardless of modality used), and had participants aged 18 and over. We examined the following outcomes: pain, using a visual analogue scale (VAS), where 0=no pain and 100=worst pain; function, using the validated Roland Morris Disability Questionnaire (RMDQ); and Kyphosis (measured in degrees). Two randomised trials including 79 patients (41 operative vs. 38 non-operative) were identified. Both trials had similar quality, patient characteristics, outcome measures, rates of follow up, and times of follow up (mean=47 months). Individual patient data meta-analysis (a powerful method of meta-analysis) was performed, since data was made available by the authors. There were no between-group differences in sex, level of fracture, mechanism of injury, follow up rates or baseline pain, kyphosis and RMDQ scores, but there was a borderline difference in age (mean 44 years in operative group vs. 39 in non-operative group, p=0.046). At final follow up, there were no between group differences in VAS pain (25 in operative group vs. 22 non-operative, p=0.63), RMDQ scores (6.1 in operative group vs. 5.8 non-operative, p=0.85), or change in RMDQ scores from baseline (4.8 in operative group vs. 5.3 non-operative, p=0.70). But both kyphosis at final follow up (11 degrees vs. 16 degrees, p=0.009) and reduction in kyphosis from baseline (1.8 degrees vs. -3.3 degrees, p=0.003) were better in the operative group. Operative management of thoracolumbar burst fractures appears to improve kyphosis, but does not improve pain or function

The progressive kyphosis and pain in patients with acute thoracolumbar burst fractures treated conservatively so as the recurrent kyphosis after posterior reduction and fixation were associated to disc collapse rather than vertebral body compression. It depends on redistribution of the disc tissue in the changed morphology of the space after fractures of the endplate. The aim of this study is to evaluate the safety and the efficacy of balloon kyphoplasty with calcium phosphate, alone or associated to short posterior instrumentation, in the treatment of acute thoracolumbar burst fractures. Eleven fractures in ten consecutive patients with an average age of 48 years who sustained acute thoracolumbar traumatic burst fractures without neurological deficits were included in this study. The fractures were A1.2 (3), A3.1 (4) and A3.2 (4), according to AO classification. In 7 fractures (A1.2 and A3.1) the kyphopasty was performed alone in order to make the most of efficacy in fracture reduction, anterior and medium column stabilization and, as much as possible, segmental kyphosis correction. In the A3.2 fractures (4), that are unstable, the kyphoplasty was associated to a short posterior instrumentation. To avoid the PMMA long run complications in younger patients, we used a calcium phosphate cement. VAS, SF-36, Roland-Morris questionnaire (RMQ) and Oswestry low back pain disability questionnaire (ODQ) were used to evaluate pain, state of health, functional outcomes and spine disability. To the average follow-up time of 15.5 months (range 8–31) we did not observe statistically significant differences in 7 of 8 SF-36 domains in comparison to general healthy population of same sex and age. At the same follow-up, the spine disability questionnaire showed a functional restriction of 18% (ODQ) and 29,6% (RMQ) being 100% the maximum of disability. No bone cement leakage, no implant failure and no height correction loss were observed in any case. Our data confirm the safety and the efficacy of ballon kyphoplasty with calcium phosphate in the treatment of acute thoracolumbar burst fractures. In this way we can reduce the possible complications resulted from discal space collapse and obtain an early functional restoration. When performed alone, this mini invasive surgical technique offer the advantage of almost immediate return to daily activities. When associated to posterior instrumentation, it decreases the long run complications and allows to reduce the number of stabilized levels, maintaining, in part, the thoracolumbar junction movement

Background: It has been reported that there is poor correlation between neurological injury and degree of bony retropulsion in thoracolumbar burst fractures. 1. Wilcox et al. 2. showed biomechanically that there was poor concordance between the extent of post impact spinal canal occlusion and the maximum amount of occlusion that occurred at the moment of impact. In the current study we examined the possibility that variation in the termination of the conus medullaris may offer protection from neurological injury in a proportion of these fractures. Methods: A retrospective study was made of 39 patients (26M:13M, mean age 35.9 years, range 15 – 75 years) presenting with a single level thoracolumbar burst fracture (T12–L2) between 1998 and 2001. A whole spine MRI scan was performed on all patients and the level of the conus noted. Age, sex, injury severity score (ISS), neurological status (ASIA motor score) and the transverse spinal canal area (TSCA) of the vertebral levels either side of the fractured vertebra was measured. A predicted TSCA for the injured level was then calculated from the mean of the TSCA’s of the adjacent levels. The actual TSCA of the injured level was calculated and this enabled a percentage decrease of the TSCA to be worked out from the predicted value. Analysis was made of the presence or absence of neurological injury in relation to canal compromise and involvement of the conus. Results: Eighteen patients with neurological compromise and 21 with intact neurology (the age and sex distribution in the two groups were similar). The mean ± SD ASIA motor score of the patients studied was 90.4 ± 23. Mean ISS was 20.2 in the neurologically injured and 10.5 in the intact (p=0.0005). Mean TSCA of the canal was 218mm. 2. in the intact and 150mm. 2. in the injured groups (p=0.006) and mean %TSCA was 70 and 49 respectively (p=0.007). The conus lay between T12 and L2 in all patients. When the conus lay cranial to the fracture (n=13), 38% were neurologically intact. When the conus lay at the level of the fracture (n=26), 62% were intact (NS). Neurological deficit did not occur in the absence of neurological compression on MRI. Conclusion: Our study showed that the risk of neurological injury from a thoracolumbar burst fracture was not decreased when the conus lay outside the fracture zone. However, there was a statistically significant difference in percentage of canal compromise when the patients with neurological impairment were compared with those that were neurologically intact

Introduction: The management of patients with thoracolumbar burst fractures has evolved over the last 60 years from the days of conservative management through to the current era of anterior decompression combined with either anterior or posterior stabilisation. There is no doubt that surgical outcomes have improved markedly with the more modern techniques. Nevertheless, there are still technical and other difficulties, which the surgeon may encounter. Based upon his experience with posterior vertebrectomy and reconstruction for thoracolumbar tumours, the author has used this technique for the management of acute burst fractures in this region. This paper presents a review of 10 patients with severe thoracolumbar burst fracture or fracture dislocation managed since 1997, using a single stage posterior decompression, realignment and stabilisation/interbody fusion. Methods: Data were acquired prospectively on consecutive patients between June 1997 and October 2000. All patients underwent single stage posterior decompression via laminectomy and then a subtotal eggshell vertebrectomy with removal of any herniated bone fragment(s) or partial vertebrectomy/ pedicle subtraction osteotomy. Pedicle screw stabilisation was performed to include one or two vertebrae above and below the involved vertebra(e). The intervertebral discs adjacent to the fractured vertebra were removed prior to realigning the vertebral column and performing inter-body fusion using carbon fibre spacers and autograft (4 patients) or vertebral body reconstruction with Titanium mesh cages and autograft (6 patients). Results: The mean age was 37 years (21–52 years). There were six males and four females. Three patients had no neurological deficit. Seven had incomplete paraplegia, three of which were severe with no or only a flicker of leg movement. The principal fracture involved L1 in 6 patients, L2 in 2, L4 in 1 and L5 in 1. Seven had herniated bone fragments occupying 90+% of the spinal canal. Of the seven patients with incomplete paraplegia, all recovered the ability to walk. Two with conus lesions still self catheterize. There were no serious early complications. A serious late complication was the development at three months of a severe deep wound infection, which required debridement and subsequent anterior/ posterior revision surgery. One patient with severe polytrauma and an L4 burst fracture/dislocation has developed a chronic pain syndrome. Discussion: The decompression, realignment, interbody reconstruction and stabilisation of thoracolumbar burst fractures/dislocations using a single stage posterior technique is technically demanding but the neurological outcome and restoration of spinal balance in these 10 patients was gratifying. The procedure appears to have two advantages over an anterior decompression and reconstruction combined with anterior or posterior stabilisation: first, it appears to provide easier access and improved visualisation for lumbar burst fractures where the psoas muscle may be swollen and contused, and second, it allows for easier realignment of any coronal or sagittal deformity

Exact knowledge of the site of the lesion, and a better understanding of the traumatic mechanisms have led to a major improvement in the surgical approach used for the treatment of thoracolumbar fractures. The first reports of a combined anterior and posterior approach recommended a two-week recovery period between the two stages. It was observed however that the rate of complications was higher and that at the time of the second stage patients had a poor nutritional status which increased the rate of mortality. It was also remarked however that a sequential approach performed on the same day could be achieved. Recently, the simultaneous anterior and posterior approach was reported by Farcy and others. Their preliminary results indicate that in terms of duration of anesthesia, blood loss, and complications, the simultaneous method is better than the sequential method. The purpose of our work was to report an analysis of the mechanical and biological benefits of the simultaneous approach for the treatment of thoracolumbar spinal fractures

To analyse the pain distribution in the acute and chronic phase following thoracolumbar fractures. Prospective observational study. 39 patients with fractures between T11 and L2, with no neurological deficit, were treated conservatively. Strict inclusion and exclusion criteria were applied. All had X-rays and MR imaging (whole spine) at post-injury and one-year follow-up. The patients documented their pain distribution using pain drawing, along with 10 other domains of pain and functional outcomes for a period over 12 months. The pain distribution was analysed. The association of distal pain distribution to - other associated injury, resultant kyphosis, Pre-existing or increase in disc degeneration at the lower non-injured disc levels – were analysed and reviewed. The most common site of the pain distribution in both the acute (90%) and chronic phase (97%) was distal to the fracture (regions - iliac crest, lumbosacral junction and buttock). Factors mentioned above that could be related to distal pain distribution did not show any significant correlation (P>0.5) with different domains of pain outcome. Some of the commonly believed reasons for distal pain distribution like resultant kyphosis and associated disc/facet pathologies were not supported by our study findings. The distal pain distribution corresponds to the scelerotomal referred pain mapping, which could be the probable explanation. Thoracolumbar pathologies could be the source of pain in patients complaining of low back symptoms. Distal pain distribution of spine pathologies should not be attributed as functional

Background. Thoracolumbar fractures are the most common spinal injuries resulting from blunt trauma. Missed spinal injuries can have serious consequences. Objective. Our objectives were to determine the utility of trauma series chest and abdomen computed tomographs for detecting clinically unrecognised vertebral fractures and to analyse those missed on clinical examination. The aim was to identify an ‘at-risk’ patient group with negative clinical examination warranting evaluation with CT screening. Material and Methods. We evaluated all computed tomography of the chest and/or abdominal that was undertaken for blunt trauma at our trauma centre from April 2009 to April 2010. Data was gathered from both CT scans and medical notes to capture demographics, mechanism of injury, fracture site and configuration. Key points were the clinical suspicion of vertebral fractures prior to CT request and identifying ‘at-risk’ patient group with factors contributing to difficulty in clinical interpretation. Results. There were a total of 303 patients in the year who underwent CT scan for blunt trauma. 51(16.8%) had a thoracolumbar vertebral fracture. There were 8 women and 43 men a mean age of 45.2 years. There were 29 (56.8%) stable and 22 (43.2%) unstable fractures. Out of the 51 total fracture patients, only 17(33.3%) had been clinically anticipated with a positive clinical examination. In the 22 unstable fractures, only 11 (50%) were expected and had clinically recorded correlating positive examination findings. Conclusion. A combination of both clinical examination and CT screening based on mechanism will likely be required to ensure adequate sensitivity with an acceptable specificity for the diagnosis of clinically significant injuries of the TL spine

The evaluation of early results of combined percutaneous pedicle screw fixation and kyphoplasty for the management of thoraco-lumbar burst fractures. Between October 2008 and April 2009, 9 patients with thoracolumbar burst fractures underwent percutaneous short-segment pedicle screw fixation and augmentation kyphoplasty with calcium phosphate cement. All patients were selected according to the type of fracture (unstable type A3 fractures based on the Magerl classification) the absence of neurological signs and an intact posterior longitudinal ligament on the pre-operative MRI scan. Patient demographics, co-morbidities and complications were recorded. The main endpoints included Cobb angle correction, vertebral body height restoration and the length of hospital stay. There were 3 male and 6 female patients with an average age of 43.6 years. The average follow-up was 2.4 months. The mean kyphotic angulation improved from 18.40 pre-operatively to 6, 80 post-operatively. The loss of vertebral body height improved from a mean of 38.7 % pre-operatively to 12.1 % post-operatively. The average duration of surgery was 40 minutes with insignificant blood loss. There were no post-operative complications. The average length of hospital stay was 3.2 days. The combination of percutaneous short-segment pedicle screw fixation supplemented by balloon kypho-plasty for the management of thoracolumbar burst fractures with no neurological deficit offers correction of the normal thoracolumbar anatomy as well as augmentation of the anterior load-bearing column, using a minimally invasive technique. The early results are promising

This study was designed to assess the inter-observer reliability and intra-observer reproducibility of standard radiographic evaluation of 150 thoracolumbar fractures, using the Magerl (AO) classification. Six observers (two junior and four senior residents) evaluated the radiographs. The injuries were classified by each observer as type A, B or C according to the Magerl classification system. After 3 months the injuries were again classified, this time with the addition of clinical findings of each patient. The level of agreement was measured using Cohen’s kappa test. The overall inter-observer agreement was rated as fair (0.291) in the first session and moderate (0.403) in the second. Intra-observer values ranged from slight (0.181) to moderate (0.488). The increased levels of agreement after the two sessions was attributed to the value of additional clinical information, the learning curve of the junior residents and the simplicity of the classification

Guidelines for cervical trauma x-rays highlight the necessity for visualization of the C7-T1 junction. However, despite 15% of thoracolumbar fractures involving the T12 vertebra, less emphasis has been placed on ensuring the thoracolumbar junction or T12 vertebra is included on lumbar trauma radiographs. This may be due to an assumption that the lower thoracic spine will routinely be seen on lumbar x-rays. We aimed to determine the proportion of lumbar trauma x-rays that allowed adequate visualisation for fracture diagnosis. We retrospectively reviewed all lumbar spine radiographs for patients presenting with blunt trauma to the Victoria Infirmary, Glasgow from January 2007 to January 2009. Our criteria for an appropriate lumbar trauma x-ray were that the whole lumbar spine should be visualized as well as the whole T12 vertebra. From 583 lumbar radiographs reviewed, 61 (10%) did not fulfill the criteria for an acceptable lumbar trauma x-ray. 3% did not include the lumbrosacral junction and 7% did not include the T12 vertebra. One patient had a delayed diagnosis of a T12 fracture due to incomplete visualisation of the T12 vertebra on initial lumbar radiographs. A significant proportion of lumbar spine x-rays performed for trauma patients (up to 10%) may not allow adequate visualisation for fracture diagnosis. These x-rays may give false reassurance that no fracture is present and, in turn, may lead to potentially disabling consequences. Spinal imaging for trauma patients should be interpreted closely with clinical findings. In cases where there is difficulty visualising the lumbar spine appropriately with radiographs, a CT scan should be considered

We hypothesised whether MIS techniques confer any benefit when treating thoracolumbar burst fractures. This was a prospective, non-randomised study over the past seven years comparing conservative (bracing:n=27), conventional surgery (open techniques:n=23) and MIS techniques (n=21) for stabilisation and correction of all thoracolumbar spinal fractures with kyphosis of >20. 0. , using Camlok S-RAD 90 system (Stryker Spine). All patients previously had normal spines, sustained only a single level burst fracture (T12, L1 or L2) as their only injury. Age range 18–65 years. All patients in both operatively treated groups were corrected to under 10. 0. of kyphosis, posteriorly only. All pedicle screws/rods were removed between 6 months and 1 year post surgery to remobilise the stabilised segments once the spinal fracture had healed, using the original incisions and muscle splitting/sparing techniques. Patients were assessed via Oswestry Disability Index (ODI) and work/leisure activity status 1 year post fracture. The conservatively treated group fared worst overall, with highest length of stay, poorest return to work/activity, and with a proportion (5/27) requiring later intervention to deal with post-traumatic deformity. 19/27 returned to original occupation, at average 9 months. ODI 32%. Conventional open techniques fared better, with length of stay 5 days, most (19/23) returning to original work/activity, and none requiring later intervention. Average return to work was at 4 months. ODI 14%. MIS group fared best, with shorter length of stay (48 hours), all returning to original work/activity at average 2 months, and none requiring later intervention. ODI negligible. There was no loss of correction in either operatively treated groups. The Camlok S-RAD 90 system is a powerful tool for correction of thoracolumbar burst fractures, and maintains an excellent correction. MIS techniques provide the best outcomes in treating this group of spinal fractures, and offer patients the best chance of restoration to pre-fracture levels of activity

We have studied the intervertebral discs adjacent to fractured vertebral bodies using MRI in 63 patients at a minimum of 18 months after injury. There were 75 thoracolumbar fractures of which 26 were treated conservatively and 37 by posterior reduction and fusion with an AO internal fixator. We identified six different types of disc using criteria based on the morphology and the intensity of the MRI signal. The inter- and intraobserver variability of this system was good. Most of the discs showed predominantly morphological changes with no variation in signal intensity. Some disc types were associated with progressive kyphosis in patients treated conservatively. In those managed by operation, recurrent kyphosis appeared to result from creeping of the disc in the central depression of the bony endplate rather than from disc degeneration. Changes in the disc space after posterior fixation should not be seen as a form of chronic instability but as a redistribution of the disc tissue in the changed morphology of the space after fractures of the endplate

Aim: To compare the radiological and functional outcomes of compression type thoracolumbar vertebral fractures treated with cloth-type thoracolumbar orthosis fitted with steel plates and bed rest. Methods: This prospective comparative study was done between July 2004 and January 2007. Twenty three patients (17 male, 6 female) with compression type (Magerl A1) thoracolumbar vertebral fractures were included. No patient had associated neurogical findings or additional injury. Eleven patients were treated with cloth-type thoracolumbar orthosis and 12 patients with only bed rest. Bed rest group cases were instructed to stand up and walk around as possible as they tolerated after pain relief just only in the house under the supervision of it’s relates. All cases were evaluated at last follow-up with SF-36 questionaire, clinical and radiological examination. Results: There was no significant difference between two groups with regard to demographic data. Radiological parameters including anterior compression angle, local kyphosis angle, sagittal index and anterior vertebral height were measured and compared on initial admittion, on the third month and at the last visit showing no significant difference (p> 0.05). Clinical evaluation was performed via work and pain criteria described by Denis. We found no significant difference between both groups for functional criteria (p> 0.05). Mental and physical points of SF-36 questionaire were recorded and compared dispaying no difference (pmental=0.15, pphysical=0.44). Conclusion: Magerl type A1 thoracolumbar fractures can be treated via bed rest by allowing controlled ambulation in home without bracing. This functional therapy can prevent complications due to absolute bed rest or related to bracing. However patient’s cooperation is the most important factor while choosing functional therapy

Purpose of the study: Kyphoplasty was introduced to reinforce the anterior column in osteoporotic vertebral fractures. It can be used for non-osteoporotic fractures. The purpose of this work was to report the clinical and radiographic results of kyphoplasty for non-ostoporotic vertebral fractures. Material and methods: From December 2005 to August 2008, we followed prospectively 21 patients (12 M, 9 F) mean age 45 years (16–58) treated for thoracolumbar fractures by kyphoplasty in order to reinforce the anterior column. There were 23 fractures (T11 = 2, T12 = 5, L1 = 8, L2 = 4, L3 = 4) Magerl: A1 = 6, A3.1 = 7, A3.2 = 1, B1 = 2, B2 = 7. All patients were assessed preoperatively, postoperatively, and at last follow-up with a visual analogue scale (VAS) and the EIFEL function score. The sagittal CT scans passing through the pedicles and the midline were used to measure: the height of the anterior and posterior walls of the fractured vertebra and the supra and infra vertebrae as well as the kyphosis angle. Results: Thirteen fractures were treated by kyphoplasty alone; seven by kyphoplasty combined with percutaneous osteosynthesis; three by kyphoplasty combined with open osteosynthesis with decompression because of preoperative neurological deficits. Mean follow-up was 13 months (6–28). There were no postoperative neurological or infectious complications. At last follow-up, the mean VAS was 1.25 (05) and the mean EIFEL 4 (0–12). Preoperatively, mean compression was 40.9% (6.2–81.4) for the anterior column and 16.7% (0–60.2) for the posterior column. Postoperatively the respective values were 22.8% (5.1–69.3) and 12.3% (−12 to 72.6) for a mean correction of 46.2% for the anterior column and 14.3% for the posterior column. At last follow-up, compression was respectively 26.1% and 7.9%. The vertebral kyphosis was 16.3 (6–16.3) preoperatively and 9.1 (3–4) postoperatively (mean correction 8.7). At last follow-up, vertebral kyphosis was 9.1 (1.7–28.3). Discussion: Kyphoplasty allows satisfactory restoration of vertebral height without loosing short-term correction. For us, kyphoplasty should be associated with posterior fixation in patients with posterior injury. For neurological lesions, kyphoplasty associated with decompression and posterior fixation avoid the need for complementary anterior procedures

Introduction: The use of an ejection seat to escape from a stricken aircraft is associated with the exposure of significant forces. These vertical accelerative forces on the body are in the order of 15–25G with rates of onset of up to 250G per second. Therefore, it is common to see vertical compression fractures, mainly in the thoracolumbar region. Although most vertebral fractures are evident on plain radiographs, subtle spinal injuries elsewhere may not be immediately apparent. Aim: A prospective study to evaluate for the presence of occult spinal injuries using MRI following aircraft ejection. Methods: Between 1996 and 2003, 22 ejectees from 18 aircrafts, mean age 32 years (range 24 to 48), were admitted to a regional spinal unit for comprehensive evaluation of their injuries that included whole spine radiographs and Magnetic Resonance Imaging (T1, T2 weighted and STIR sagittal sequences). All ejections occurred within the ejection envelope and were flying below 2000 ft (mean 460 feet) and below 500 knots airspeed (mean 275 knots). Results: All 5 ejectees (23%) with vertebral compression fractures, one at T6 and 4 in thoracolumbar region, had pain and tenderness in the appropriate area of the spine that was evidently detected on plain radiographs. 3 of these patients with a thoracolumbar fracture (AO A3.3) had more than 50% canal compromise and more than 30 degrees angular kyphosis underwent surgery. Neurological compromise consisting of acute cauda equina syndrome occurred in one patient with a L2 AO A3.3 fracture. More importantly 10 ejectees (45%) had MRI evidence totalling 21 occult thoracic and lumbar vertebral fractures. 4 ejectees had a single occult fracture, 4 had double, 1 had 3 and 1 had 6 occult fractures. Conclusion: This study confirms the high incidence of occult vertebral injuries following vertical acceleration insult to the spine consequent to emergency aircraft ejection. Once life-saving priority measures have taken place MRI of the entire spine remains mandatory as part the comprehensive evaluation of the patient. Early use of MRI scanning in the management will significantly increase an ejectee’s safe return to flying duties

Purpose: Minimally invasive video-assisted thoracotomy can be proposed for potentially unstable fractures of the thoracolumbar junction with rupture of the anterior column after satisfactory posterior reduction and osteo-synthesis. Long-term results are improved in terms of graft quality and stability of the postoperative angular gain. Material and methods: Ninety-one patients, mean age 36 years, with spinal fractures involving T12 to L2 underwent video-assisted mini-thoracotomy for arthrodesis as a complementary procedure after posterior reduction and osteosynthesis without bone graft. The left approach was preferred over the right due to the lower risk of bleeding. A massive tricortical anterolateral iliac graft was inserted in the intersomatic space. Perfect stability was achieved with the MIASPAS system which provides an exact measure of the intersomatic space and the bone graft. Results: Follow-up was five years for the first patients and ten months for those operated on after January 2003. At last follow-up, functional outcome (Stauffer-Coventry score) was excellent or good in 52% and 41% of the patients respectively. Outcome was poor in 7%. Postoperative radiograms demonstrated 100% graft fusion which was confirmed by tomography. There was no loss of angular gain. Discussion: This novel approach provides a means of preserving the posterior instrumentation and achieving anterior fusion in the zone of maximal stress. Because of the relative facility of the technique together with the operative time and the relatively low risk of postoperative complications, surgical indications for complementary intersomatic arthrodesis can be revisited. Anterior fusion is, in our opinion, the only sure means of maintaining long-term correction. The ability to access the disc, generally without metameric hemostasis, eliminates the risk of vascular cord lesions. Conclusion: This thoracoscopic technique for anterior fusion after a short posterior osteosyntheis without graft will greatly modify indications for complementary anterior fusion for the treatment of unstable thoracolumbar fractures

The Mater Hospital is Ireland’s primary referral centre for spinal injuries receiving 80–90% of all spinal cases annually. In today’s society the number of people competing at more competitive and professional levels is also increasing. Over the years, a lot of work has gone into safety precautions in sport. However despite those improvements our impression was that the incidence of both minor and serious sporting injuries is increasing. The purpose of this study was to determine the incidence, pattern and mechanism of sports-related spinal injuries in Ireland over the last decade. Data was collected by performing an audit of the National Spinal Injuries Database from 1994–2001. This database is a prospective computerized database. Data entered relates to the initial presentation, mechanism, level of injury and their acute in-hospital management. On average 200–220 patients are admitted annually to the National Injuries Spinal Unit. 173 of these were related to sport, which represented 13% of total spinal injuries. 80% are male under 40 years. 29% sustained neurological deficit. The sports responsible for most spinal injuries in Ireland were equestrian (43.8%), followed by rugby (16.4%), diving (15%), GAA (13.6%) and skiing (3%). Rugby injuries were most likely to cause neurological damage. Equestrian accidents commonly caused thoracolumbar fractures while injuries sustained in diving, rugby and GAA were mostly to the cervical spine. Sport is an important cause of spinal injuries in Ire-land. Coaches and team doctors must be educated about safe practices and emergency management of these terrible injuries and for those unfortunately affected in the prime of their lives adequate rehabilitation resources need to be implemented so as to lessen their economic burden

The October 2012 Spine Roundup. 360. looks at: a Japanese questionnaire at work in Iran; curve progression in degenerative lumbar scoliosis; the cause of foot drop; the issue of avoiding the spinal cord at scoliosis surgery; ballistic injuries to the cervical spine; minimally invasive oblique lumbar interbody fusion; readmission rates after spinal surgery; clinical complications and the severely injured cervical spine; and stabilising the thoracolumbar burst fracture