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

To analyse and compare long-term functional outcome of combined spino-pelvic injuries to an isolated pelvis and spinal fractures, the outcome of matched 30 patients with combined pelvic and spinal fractures was compared with 32 patients with isolated pelvic fractures and 30 patients with isolated spinal fractures. Functional outcome was measured using the self-report questionnaire EuroQol EQ-5D, a generic outcome tool. The functional outcome was compared with the average UK population scores. The mean age, median ISS and demographic profile were similar in all 3 groups. Neurological injuries were seen in 10 patients in the combined injury group, 5 patients in the pelvic injury group and 3 patients in the spinal fracture group. 1 patient had sexual dysfunction in the combined injury group. The EuroQol EQ-5D descriptive scores for the combined group were 0.67±0.11 (0.71±0.12 for spine fracture, 0.61±0.18 for pelvic fracture) and Valuation scores for the combined injury were 69.6±11.4 (65.1±19.4 for spine fracture, 61.5±21.9 for pelvic fracture), which are p=0.004 and p=0.003 for the combined injury compared to the average UK population. Duration of hospital stay was a mean of 13 days in spine injury group compared to 49 days in the combined injury group. 70% of patients with spinal injuries returned to the same level of employment in a mean duration of 5.3 months with only 10% retired due to injury; compared to 56.6% returned to work in the combined injury group after a mean duration of 12.8 months with 23.3% retired due to injury. Long-term functional outcome is significantly better with isolated spinal injuries compared to pelvic injury or combined injury. There is no significant long-term difference between the combined spino-pelvic group and the isolated pelvic injury group. We feel that the spinal injuries in a patient with coexisting pelvic fracture do not contribute towards the overall functional outcome in those patients

INTRODUCTION. Tibiofemoral contact at the base of the articular surface spine in posterior-stabilized total knee arthroplasty (TKA) implants can lead to spine fracture [1]. Revision TKA implants also have an articular surface spine to provide sufficient constraint when soft tissues are compromised. While some revision TKA designs have metal reinforcement in the articular surface spine, others rely solely on a polyethylene spine. This study used finite element analysis (FEA) to study the effect of metal reinforcement on stresses in the spine when subjected to posteriorly directed loading. METHODS. Two clinically successful Zimmer Biomet revision TKA designs were selected; NexGen LCCK with metal reinforcement and all-poly Vanguard SSK. The largest sizes were selected. FEA models consisted of the polyethylene articular surface and a CoCr femoral component; LCCK also included a CoCr metal reinforcement in the spine. A 7° and 0° tibial slope, as well as 3° and 0.7° femoral hyperextension, were used for the LCCK and SSK, respectively. A posteriorly directed load was applied to the spine through the femoral component (Figure 1). The base of the articular surface was constrained. The articular surfaces for both designs are made from different polyethylene materials. However, for the purpose of this study, to isolate the effect of material differences on stresses, both were modeled using conventional GUR1050 nonlinear polyethylene material properties. Femoral component and metal reinforcement were modeled using linear elastic CoCr properties. Additionally, the LCCK was reanalyzed by replacing the metal reinforcement component with polyethylene material, in order to isolate the effect of metal reinforcement for an otherwise equivalent design. Frictional sliding contact was modeled between the spine and femoral/metal reinforcement components. Nonlinear static analyses were performed using Ansys version 17 software and peak von mises stresses in the spine were compared. RESULTS. Peak von mises stresses were predicted towards the base of the anterior aspect of the spine in both designs (Figure 2). In LCCK, the high stresses were also predicted on the medial and lateral edges of the anterior spine, matching the tibiofemoral contact (Figure 3). The LCCK with metal reinforcement design predicted 14% and 31% lower stress than LCCK and SSK all-poly designs. DISCUSSION. Clinical reports of spine fracture in TKA highlight the need for further understanding of the biomechanics of spine loading. Here, through comparison of two clinically successful devices, the effect of multiple design factors was quantified. Inclusion of metal reinforcement in the spine, as well as differences in the conforming geometry between the femoral component and the articular surface, resulted in a 31% decrease in polyethylene stress for the LCCK as compared to the all-poly SSK; of which only 16% was attributed to the metal reinforcement. Further improvements to articular surface design, as well as polyethylene material advances, have the potential to result in all-poly designs with strength characteristics equivalent to or exceeding those of designs with metal reinforcement

Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes. Our objective was to determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day post-operative complication rates. This study was a multicenter retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. All anterior cervical or posterior lumbar fusion surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery and emergency surgery were excluded. Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay and 30 day post-operative complication rates. 1441 patients met the inclusion criteria: 1142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertile of predicted surgery duration, cervical or lumbar surgery, instrumentation, inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, lumbar fusion surgery and inpatient surgery. There were no significant differences reported for any other factors. After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates, length of hospital stay or surgical duration of more routine surgical cases. We found that resident involvement in surgical cases that were generally more complexed resulted in increased surgery time. Further study is required to determine the relationship between surgery complexity and the effect of resident involvement on surgery duration

Introduction. This is the first study to illustrate spinal fracture distribution and the impact of different injury mechanisms on the spinal column during contemporary warfare. Methods. A retrospective analysis of Computed Tomography (CT) spinal images entered onto the Centre for Defence Imaging (CDI) database, 2005-2009. Isolated spinous and transverse process fractures were excluded to allow focus on cases with implications for immediate management and prospective disability burden. Fractures were classified by anatomical level and stability with validated systems. Clinical data regarding mechanism of injury and associated non-spinal injuries for each patient were recorded. Statistical analysis was performed using Fisher's Exact test. Results. 57 cases (128 fractures) were analysed. Ballistic (79%) and non-ballistic (21%) mechanisms contribute to vertebral fracture and spinal instability at all regions of the spinal column. There is a low incidence of cervical spine fracture, with these injuries predominantly occurring due to gunshot wounding. There is a high incidence of lumbar spine fractures which are significantly more likely to be caused by explosive devices than gunshot wounds (p<0.05). 66% of thoracolumbar spine fractures caused by explosive devices were unstable, the majority being of a burst configuration. Associated non-spinal injuries occurred in 60% of patients. There is a strong relationship between spinal injuries caused by explosive devices and lower limb fractures. Conclusion. Explosive devices account for significant injury to both combatants and civilians in current conflict. Injuries to the spine by explosions account for greater numbers, associated morbidity and increasing complexity than other means of injury

Spinal fractures are common following underbody blast. Most injuries occur at the thoracolumbar junction, and fracture patterns suggest the spine is flexed at the moment of injury. However, current mechanistic descriptions of vertebral fractures are based on low energy injuries, and there is no evidence to correlate fracture pattern with posture at the loading rates seen in blast injury. The T12-L1 segment of 4 human spines was dissected to preserve the paraspinal ligaments and potted in polymethylmecrylate. The specimens were impacted with a 14 kg mass at 3.5m/s in a drop tower; two specimens were impacted in neutral posture, one in flexion, and one in extension. A load cell measured the load history. CT scans and dissection identified the injury patterns. Each specimen sustained a burst fracture. The neutral specimens demonstrated superior burst fractures, the flexed specimen demonstrated a superior burst fracture with significant anterior involvement, and the extended specimen showed a posterior vertebral body burst fracture. At high loading rates, the posture of the spine at the moment of injury appears to affect the resulting fracture. This supports understanding the behaviour of the spine in blast injury and will allow improved mitigation system design in the future

Purpose:. Non-contiguous spinal injury can add significant complexity to the diagnosis, management and outcome in children. There is very little in the paediatric literature examining the nature, associated risk factors, management and outcomes of non-contiguous spinal injuries. The objective is to determine the incidence and clinical characteristics of non-contiguous spinal injuries in a paediatric population. The secondary objective is to identify high risk patients requiring further imaging to rule out non-contiguous spinal injuries. Methods:. All children up to 18 years of age with a spinal injury, as defined by ICD-09 codes at one paediatric trauma hospital were included (n=211). Data for patient demographics, mechanism of injury, spinal levels involved, extent of neurologic injury and recovery, associated injuries, medical complications, treatment and outcome were recorded. Results:. Twenty five (11.8%) out of 211 patients had non-contiguous spinal injuries. The mean age was 10.7 years. The most common pattern of injury was a double thoracic non-contiguous injury. 16% of cases of NCSI were initially missed, but with no clinical deterioration due to the missed diagnosis. Associated injuries occurred in 52% of patients with NCSI. Twenty-four percent of patients with multiple non-contiguous spinal injuries had a neurologic injury compared to 9.7% in patients with single level or contiguous injuries (p=0.046). Conclusions:. There is a high incidence of children with multiple non-contiguous spinal injuries who are more likely to suffer neurological injuries compared to patients with single level or contiguous spinal injuries. Patients with a single level spinal injury on existing imaging and a neurological injury should have entire spine lateral radiographs to exclude non-contiguous injuries. In patients without neurologic injury and a single spinal fracture, radiographs showing at least 7 levels above and below the fracture should be performed. All children with spinal injury should have associated injuries carefully excluded

Introduction. Traditionally complex spinal surgery in Belfast has been performed at the Royal Victoria Hospital (RVH). Since an amalgamation the RVH has become effectively the level 1 trauma centre for the province. The ever increasing complexity of spinal surgery in addition to changes in practice such as the management of metastatic spinal cord, are placing significant demands on the service. At a time when resources are scarce trends in patient profiles are highly important to allow adequate planning of our service. Aim. To establish trends in patient profiles in a level one trauma centre also managing spinal pathology over the last 10 years and to examine the impact of this on our service. Methods. The Fracture Outcome Research Data base (FORD) was interrogated to provide data for patient profiles from 2000 to 2010. The Hospital planning and performance department contacted for finance data. Results. In 2000 the most common admission was for a fractured neck of femur (n=1014). This has not significantly changed over the ten years. In 2000 fractured tibia (n= 386), fractured forearms (n= 324), fractured ankles (n= 312) and spinal cases (n=335) were admitted. By 2010 a 49% increase had occurred in spinal admissions making them the second most common patient admitted to the unit. Of spinal case admissions, tumours have increased by 333%, spinal fractures by 10%, cervical disc surgery by 163% and suspected cauda equine cases by a staggering 537%. Conclusions. The throughput of spinal admissions to the unit has significantly increased between 2000 and 2010 making them now the second most common admission to the unit. The impact of this on bed days, theatre usage and oncall arrangements is huge and must be taken into account in stratregic planning of our service especially given the background of ongoing financial constraint

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

Background. High velocity vertical aircraft ejection seat systems are credited with aircrew survival of 80-95% in modern times. Use of these systems is associated with exposure of the aircrew to vertical acceleration forces in the order of 15-25G. The rate of application of these forces may be up to 250G per sceond. Up to 85% of crew ejecting suffer skeletal injury and vertebral fracture is relatively common (20-30%) when diagnosed by plain radiograph. The incidence of subtle spinal injury may not be as apparent. Aim. A prospective study to evaluate spinal injury following high velocity aircraft ejection. Methods. A prospective case series from 1996 to 2006 was evaluated. During this interval 26 ejectees from 20 aircraft were admitted to the spinal studies unit for comprehensive examination, evaluation and management. The investigations included radiographs of the whole spine and Magnetic Resonance Imaging (incorporating T1, T2 weighted and STIR sagittal sequences). All ejections occurred within the ejection envelope and occurred at an altitude under 2000 feet (mean 460 feet) and at an airspeed less than 500 knots (mean 275 knots). Results. in this series 6 ejectees (24%) had clinical and radiographic evidence of vetebral compression fractures. These injuries were located in the thoracic and thoracolumbar spine. 4 cases required surgery (indicated for angular kyphosis greater than 30 degrees, significant spinal canal compromise, greater than 50% or neurological injury. 1 patient had significant neurological compromise, following an AO A3.3 injury involving the L2 vertebra. 11 ejectees (45 %) had MRI evidence of a combined total of 22 occult thoracic and lumbar fractures. The majority of these ejectees with occult injury had multilevel injuries. Conclusion. This study confirms a high incidence of spinal fracture and particularly occult spinal injury

Aims

The aim of this paper is to describe the impact of COVID-19 on spine surgery services in a district general hospital in England in order to understand the spinal service provisions that may be required during a pandemic.

During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19.