Purpose. The treatment of C2 fractures with collar, halo or surgery can all be justified depending on the patient. In our unit, primary treatment is with a halo: in a previous study presented at BASS we found an 85% fusion rate. In a follow on study, we wished to assess the outcome in those patients who underwent surgical treatment. Methods. The discharge logbook was examined retrospectively to identify patients who had posterior instrumentation for C2 fractures from 2008-2010 inclusive. Discharge summaries, clinic letters and radiology images/reports from PACS were analysed to obtain data regarding primary treatment, outcome, necessity for delayed treatment and radiological evidence of union. Results. Seven patients were identified who had surgery for C2 fracture. All 7 patients were treated with C1 and C2 lateral mass screws. In two of these patients additional lateral mass screws were inserted at C3. Due to patient preference, three of the seven patients underwent operative fixation without prior treatment in a halo. All three patients had evidence of bony union at the fracture site on subsequent radiological follow up. The remaining four patients were initially treated in a halo and had delayed surgery. After surgery two of these four patients had radiological evidence of bony union at the fracture site, one remained non-united and one patient has not yet been fully assessed. Conclusions. In this small series, operative fixation for C2 fracture lead to bony union at the fracture site in 5 out of 6 cases where full follow up was available. Interestingly, bony union at the fracture site may be an achievable objective even when surgery has been delayed or is not the primary treatment

Many operations have been recommended to treat Pars Interarticularis fractures that have separated and are persistently symptomatic, but little other than conservative treatment has been recommended for symptomatic incomplete fractures. 10 consecutive patients aged 15–28 [mean 21.7 years] were treated operatively between 2010–2014. All but one were either professional athletes [3 cricketers, 2 athletics, 1 soccer] or academy cricketers [3 patients]. 8 patients had unilateral fractures, and two had bilateral fractures at the same level. The duration of pre-operative pain and disability with exercise ranged from 4–24 months [mean 15.4 months]. The operation consists of a percutaneous compression screw inserted through a 1.5cm midline skin incision under fluoroscopic guidance: 6 cases were also checked with the O-arm intra-operatively. Post-operation the patients were mobilised with a simple corset and discharged the following day with a customised rehabilitation program. All 12 fractures in 10 patients healed as demonstrated on post-operative CT scans at between 3–6 months. One patient had the screw revised at 24 hours for an asymptomatic breach, and one patient developed a halo around the fracture site without screw loosening, and had a successful revision operation to remove the screw and graft the pars from the screw channel. All patients achieved a full return to asymptomatic activity, within a timescale of 4–12 months post-surgery, depending on the sport. Athletes that have persistent symptoms from incomplete pars interarticularis fractures should consider percutaneous fixation rather than undergoing prolonged or repeated periods of rest

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

Spinal Biomechanics Lab, Baylor College of Medicine, Houston, Texas, USA. Documenting the patterns and frequency of collapse in non-operatively managed spine fractures, using a motion analysis software. Retrospective analysis of prospective case series. 105 patients with thoracic or lumbar fractures, were neurologically intact, and treated non-operatively for the ‘stable’ injury at our unit between June 2003 and May 2006. The mean age of the cohort was 46.9 yrs. Serial radiographs (mean 4 radiographs/patient; range 2 – 9) were analysed using motion analysis software for collapse at the fracture site. We defined collapse as a reduction of anterior or posterior vertebral body height greater than 15% of the endplate AP width, or a change in the angle between the inferior and superior endplates > 5°. The changes were assessed on serial radiographs performed at a mean of 5.6 mo (95% CI 4.1 – 7.1 mo) after the initial injury. 11% showed anterior collapse, 7.6% had posterior collapse, 14% had collapse apparent as vertebral body wedging, and 17% had any form of collapse. ODI scores were obtained in 35 patients at the time of the last available radiograph. There were no significant differences in ODI scores that could be associated with the presence of any form of collapse (p > 0.8 for anterior collapse; and p = 0.18 for posterior collapse). This pilot study with the motion analysis software demonstrates that some fractures are more likely to collapse with time. We hope to carry this work forward by way of a prospective study with a control on other variables that are likely to affect the pattern and probability of post-fracture collapse, including age, bone density, vertebral level, activity level, fracture type

Objectives

Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients.

Aims

We performed a retrospective, comparative study of elderly patients with an increased risk from anaesthesia who had undergone either anterior screw fixation (ASF) or halo vest immobilisation (HVI) for a type II odontoid fracture.

Ventral screw osteosynthesis is a common surgical method for treating fractures of the odontoid peg, but there is still no consensus about the number and diameter of the screws to be used. The purpose of this study was to develop a more accurate measurement technique for the morphometry of the odontoid peg (dens axis) and to provide a recommendation for ventral screw osteosynthesis.

Images of the cervical spine of 44 Caucasian patients, taken with a 64-line CT scanner, were evaluated using the measuring software MIMICS. All measurements were performed by two independent observers. Intraclass correlation coefficients were used to measure inter-rater variability.

The mean length of the odontoid peg was 39.76 mm (sd 2.68). The mean screw entry angle α was 59.45° (sd 3.45). The mean angle between the screw and the ventral border of C2 was 13.18° (sd 2.70), the maximum possible mean converging angle of two screws was 20.35° (sd 3.24). The measurements were obtained at the level of 66% of the total odontoid peg length and showed mean values of 8.36 mm (sd 0.84) for the inner diameter in the sagittal plane and 7.35 mm (sd 0.97) in the coronal plane. The mean outer diameter of the odontoid peg was 12.88 mm (sd 0.91) in the sagittal plane and 11.77 mm (sd 1.09) in the coronal plane. The results measured at the level of 90% of the total odontoid peg length were a mean of 6.12 mm (sd 1.14) for the sagittal inner diameter and 5.50 mm (sd 1.05) for the coronal inner diameter. The mean outer diameter of the odontoid peg was 11.10 mm (sd 1.0) in the sagittal plane and 10.00 mm (sd 1.07) in the coronal plane. In order to calculate the necessary screw length using 3.5 mm cannulated screws, 1.5 mm should be added to the measured odontoid peg length when anatomical reduction seems possible.

The cross-section of the odontoid peg is not circular but slightly elliptical, with a 10% greater diameter in the sagittal plane. In the majority of cases (70.5%) the odontoid peg offers enough room for two 3.5 mm cannulated cortical screws.

Cite this article: Bone Joint J 2013;95-B:536–42.

The purpose of this study was to determine whether patients with a burst fracture of the thoracolumbar spine treated by short segment pedicle screw fixation fared better clinically and radiologically if the affected segment was fused at the same time. A total of 50 patients were enrolled in a prospective study and assigned to one of two groups. After the exclusion of three patients, there were 23 patients in the fusion group and 24 in the non-fusion group. Follow-up was at a mean of 23.9 months (18 to 30). Functional outcome was evaluated using the Greenough Low Back Outcome Score. Neurological function was graded using the American Spinal Injury Association Impairment Scale. Radiological outcome was assessed on the basis of the angle of kyphosis.

Peri-operative blood transfusion requirements and duration of surgery were significantly higher in the fusion group (p = 0.029 and p < 0.001, respectively). There were no clinical or radiological differences in outcome between the groups (all outcomes p > 0.05). The results of this study suggest that adjunctive fusion is unnecessary when managing patients with a burst fracture of the thoracolumbar spine with short segment pedicle screw fixation.