Browsing by Subject "Spinal Fractures"
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Item Open Access Assessment of symptomatic rod fracture after posterior instrumented fusion for adult spinal deformity.(Neurosurgery, 2012-10) Smith, Justin S; Shaffrey, Christopher I; Ames, Christopher P; Demakakos, Jason; Fu, Kai-Ming G; Keshavarzi, Sassan; Li, Carol MY; Deviren, Vedat; Schwab, Frank J; Lafage, Virginie; Bess, Shay; International Spine Study GroupBackground
Improved understanding of rod fracture (RF) in adult spinal deformity could be valuable for implant design, surgical planning, and patient counseling.Objective
To evaluate symptomatic RF after posterior instrumented fusion for adult spinal deformity.Methods
A multicenter, retrospective review of RF in adult spinal deformity was performed. Inclusion criteria were spinal deformity, age older than 18 years, and more than 5 levels posterior instrumented fusion. Rod failures were divided into early (≤12 months) and late (>12 months).Results
Of 442 patients, 6.8% had symptomatic RF. RF rates were 8.6% for titanium alloy, 7.4% for stainless steel, and 2.7% for cobalt chromium. RF incidence after pedicle subtraction osteotomy (PSO) was 15.8%. Among patients with a PSO and RF, 89% had RF at or adjacent to the PSO. Mean time to early RF (63%) was 6.4 months (range, 2-12 months). Mean time to late RF (37%) was 31.8 months (range, 14-73 months). The majority of RFs after PSO (71%) were early (mean, 10 months). Among RF cases, mean sagittal vertical axis improved from preoperative (163 mm) to postoperative (76.9 mm) measures (P<.001); however, 16 had postoperative malalignment (sagittal vertical axis>50 mm; mean, 109 mm).Conclusion
Symptomatic RF occurred in 6.8% of adult spinal deformity cases and in 15.8% of PSO patients. The rate of RF was lower with cobalt chromium than with titanium alloy or stainless steel. Early failure was most common after PSO and favored the PSO site, suggesting that RF may be caused by stress at the PSO site. Postoperative sagittal malalignment may increase the risk of RF.Item Open Access Biomechanics, evaluation, and management of subaxial cervical spine injuries: A comprehensive review of the literature.(Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 2021-01) Wang, Timothy Y; Mehta, Vikram A; Dalton, Tara; Sankey, Eric W; Rory Goodwin, C; Karikari, Isaac O; Shaffrey, Christopher I; Than, Khoi D; Abd-El-Barr, Muhammad MStudy design
Literature review.Objectives
It has been reported that 2.4-3.7% of all blunt trauma victims suffer some element of cervical spine fracture, with the majority of these patients suffering from C3-7 (subaxial) involvement. With the improvement of first-response to trauma in the community, there are an increasing number of patients who survive their initial trauma and thus arrive at the hospital in need of further evaluation, stabilization, and management of these injuries.Methods
A comprehensive literature review compiled all relevant data on the biomechanics, imaging, evaluation, and medical and surgical management strategies for subaxial cervical spine fractures.Results
After review of the current literature on subaxial cervical spine biomechanics, imaging characteristics, evaluation strategies and surgical and orthopedic management techniques, the authors created a comprehensive review and protocol for management of subaxial cervical spine fractures.Conclusions
The subaxial cervical spine is biomechanically and anatomically unique from the remainder of the spinal axis. Evaluation of subaxial cervical spine injuries is nuanced, and improper management of these injuries can lead to significant patient morbidity and even death. This provides a comprehensive review combining anatomy, imaging characteristics, evaluation strategies, and surgical and orthopedic management principles for subaxial cervical spine fractures.Item Open Access C-2 neurectomy during atlantoaxial instrumented fusion in the elderly: patient satisfaction and surgical outcome.(Journal of neurosurgery. Spine, 2011-07) Hamilton, D Kojo; Smith, Justin S; Sansur, Charles A; Dumont, Aaron S; Shaffrey, Christopher IObjective
The originally described technique of atlantoaxial stabilization using C-1 lateral mass and C-2 pars screws includes a C-2 neurectomy to provide adequate hemostasis and visualization for screw placement, enable adequate joint decortication and arthrodesis, and prevent new-onset postoperative C-2 neuralgia. However, inclusion of a C-2 neurectomy for this procedure remains controversial, likely due in part to a lack of studies that have specifically addressed whether it affects patient outcome. The authors' objective was to assess the surgical and clinical impact of routine C-2 neurectomy performed with C1-2 segmental instrumented arthrodesis in a consecutive series of elderly patients with C1-2 instability.Methods
Forty-four consecutive patients (mean age 71 years) underwent C1-2 instrumented fusion, including C-1 lateral mass screw insertion. Bilateral C-2 neurectomies were performed. Standardized clinical assessments were performed both pre- and postoperatively. Numbness or discomfort in a C-2 distribution was documented at follow-up. Fusion was assessed using the Lenke fusion grade.Results
Among all 44 patients, mean blood loss was 200 ml (range 100-350 ml) and mean operative time was 129 minutes (range 87-240 minutes). There were no intraoperative complications, and no patients reported new postoperative onset or worsening of C-2 neuralgia postoperatively. Outcomes for the 30 patients with a minimum 13-month follow-up (range 13-72 months) were assessed. At a mean follow-up of 36 months, Nurick grade and pain numeric rating scale scores improved from 3.7 to 1.0 (p < 0.001) and 9.4 to 0.6 (p < 0.001), respectively. The mean postoperative Neck Disability Index score was 7.3%. The fusion rate was 97%, and the patient satisfaction rate was 93%. All 24 patients with preoperative occipital neuralgia reported relief. Seventeen patients noticed C-2 distribution numbness only during examination in the clinic, and 2 patients reported C-2 numbness, but it did not affect their daily function.Conclusions
In this series of C1-2 instrumented arthrodesis in elderly patients, excellent fusion rates were achieved, and patient satisfaction was not negatively affected by C-2 neurectomy. In the authors' experience, C-2 neurectomy enhanced surgical exposure of the C1-2 joint, thereby facilitating hemostasis, placement of instrumentation, and decortication of the joint space for arthrodesis. Importantly, with C-2 neurectomy in the present series, no cases of new onset postoperative C-2 neuralgia occurred, in contrast to a growing number of reports in the literature documenting new-onset C-2 neuralgia without C-2 neurectomy. On the contrary, 80% of patients in the present series had preoperative occipital neuralgia and in all of these patients this neuralgia was relieved following C1-2 instrumented arthrodesis with C-2 neurectomy.Item Open Access Complications associated with surgical treatment of traumatic spinal fractures: a review of the scoliosis research society morbidity and mortality database.(World neurosurgery, 2014-05) Williams, Brian J; Smith, Justin S; Saulle, Dwight; Ames, Christopher P; Lenke, Lawrence G; Broadstone, Paul A; Vaccaro, Alexander R; Polly, David W; Shaffrey, Christopher IObjective
Traumatic spinal fracture is a common indication for surgery, with an associated high incidence of perioperative complications. The literature provides a wide range in the incidence of complications. We seek to assess the perioperative morbidity and mortality of surgery for traumatic spinal fractures and to identify predictors of their occurrence.Methods
We performed a retrospective analysis of all traumatic spinal fracture cases submitted by members of the Scoliosis Research Society from 2004 to 2007.Results
A total of 108,478 cases were submitted from 2004 through 2007, with 6,706 (6.2%) performed for treatment of traumatic fracture. Twenty-two percent of patients had preoperative neurological deficits. Intraoperative neuromonitoring was used in 58% of cases. The overall incidence of complications was 6.9%. The perioperative mortality was 0.5%. There were 59 (0.9%) new postoperative neurological deficits. Multivariate analysis demonstrated preoperative neurological deficit (P = .001; odds ratio [OR] 1.449, 95% confidence interval [CI] [1.156 to 1.817]) and fusion (P =.001; OR 1.12, 95% CI [1.072 to 1.168]) as predictors of complications and use of intraoperative neuromonitoring (P = .016; OR 1.949, 95% CI [1.13 to 3.361]), and preoperative neurological deficit (P < .001; OR 2.964, 95% CI [1.667 to 5.271]) as predictors of new postoperative neurological deficits (P < .001).Conclusions
Overall, surgery for the treatment of spinal fractures was performed with relatively low incidences of perioperative complications (6.9%) and mortality (0.5%). These data may prove useful for patient counseling and ongoing efforts to improve the safety of operative care for patients with spinal fracture.Item Open Access Depression and outcome.(Journal of neurosurgery. Spine, 2014-08) Shaffrey, Christopher I; Smith, Justin SItem Open Access Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture.(The Journal of bone and joint surgery. American volume, 2013-04) Vaccaro, Alexander R; Kepler, Christopher K; Kopjar, Branko; Chapman, Jens; Shaffrey, Christopher; Arnold, Paul; Gokaslan, Ziya; Brodke, Darrel; France, John; Dekutoski, Mark; Sasso, Rick; Yoon, S Tim; Bono, Christopher; Harrop, James; Fehlings, Michael GBackground
Dens fractures are relatively common in the elderly. The treatment of Type-II dens fractures remains controversial. The aim of this multicenter prospective cohort study was to compare outcomes (assessed with use of validated clinical measures) and complications of nonsurgical and surgical treatment of Type-II dens fractures in patients sixty-five years of age or older.Methods
One hundred and fifty-nine patients with a Type-II dens fracture were enrolled in a multicenter prospective study. Subjects were treated either surgically (n = 101) or nonsurgically (n = 58) as determined by the treatment preferences of the treating physicians and the patients. The subjects were followed at six and twelve months with validated outcome measures, including the Neck Disability Index (NDI) and Short Form-36v2 (SF-36v2). Treatment complications were prospectively recorded. Statistical analysis was performed to compare outcome measures before and after adjustment for confounding variables.Results
The two groups were similar with regard to baseline characteristics. The most common surgical treatment was posterior C1-C2 arthrodesis (eighty of 101, or 79%) while the most common nonsurgical treatment was immobilization with use of a hard collar (forty-seven of fifty-eight, or 81%). The overall mortality rate was 18% over the twelve-month follow-up period. At twelve months, the NDI had increased (worsened) by 14.7 points in the nonsurgical cohort (p < 0.0001) compared with a nonsignificant increase (worsening) of 5.7 points in the surgical group (p = 0.0555). The surgical group had significantly better outcomes as measured by the NDI and SF-36v2 Bodily Pain dimension compared with the nonsurgical group, and these differences persisted after adjustment. There was no difference in the overall rate of complications, but the surgical group had a significantly lower rate of nonunion (5% versus 21% in the nonsurgical group; p = 0.0033). Mortality was higher in the nonsurgical group compared with the surgical group (annual mortality rates of 26% and 14%, respectively; p = 0.059).Conclusions
We demonstrated a significant benefit with surgical treatment of dens fractures as measured by the NDI, a disease-specific functional outcome measure. As a result of the nonrandomized nature of the study, the results are vulnerable to the effects of possible residual confounding. We recommend that elderly patients with a Type-II dens fracture who are healthy enough for general anesthesia be considered for surgical stabilization to improve functional outcome as well as the union and fusion rates.Item Open Access Incidence, mode, and location of acute proximal junctional failures after surgical treatment of adult spinal deformity.(Spine, 2013-05) Hostin, Richard; McCarthy, Ian; OʼBrien, Michael; Bess, Shay; Line, Breton; Boachie-Adjei, Oheneba; Burton, Doug; Gupta, Munish; Ames, Christopher; Deviren, Vedat; Kebaish, Khaled; Shaffrey, Christopher; Wood, Kirkham; Hart, Robert; International Spine Study GroupStudy design
Multicenter, retrospective series.Objective
To analyze the incidence, mode, and location of acute proximal junctional failures (APJFs) after surgical treatment of adult spinal deformity.Summary of background data
Early proximal junctional failures above adult deformity constructs are a serious clinical problem; however, the incidence and nature of early APJFs remain unclear.Methods
A total of 1218 consecutive adult spinal deformity surgeries across 10 deformity centers were retrospectively reviewed to evaluate the incidence and nature of APJF, defined as any of the following within 28 weeks of index procedure: minimum 15° post-operative increase in proximal junctional kyphosis, vertebral fracture of upper instrumented vertebrae (UIV) or UIV + 1, failure of UIV fixation, or need for proximal extension of fusion within 6 months of surgery.Results
Sixty-eight APJF cases were identified out of 1218 consecutive surgeries (5.6%). Patients had a mean age of 63 years (range, 26-82 yr), mean fusion levels of 9.8 (range, 4-18), and mean time to APJF of 11.4 weeks (range, 1.5-28 wk). Fracture was the most common failure mode (47%), followed by soft-tissue failure (44%). Failures most often occurred in the thoracolumbar region (TL-APJF) compared with the upper thoracic region (UT-APJF), with 66% of patients experiencing TL-APJF compared with 34% experiencing UT-APJF. Fracture was significantly more common for TL-APJF relative to UT-APJF (P = 0.00), whereas soft-tissue failure was more common for UT-APJF (P < 0.02). Patients experiencing TL-APJF were also older (P = 0.00), had fewer fusion levels (P = 0.00), and had worse postoperative sagittal vertical axis (P < 0.01).Conclusion
APJFs were identified in 5.6% of patients undergoing surgical treatment of adult spinal deformity, with failures occurring primarily in the TL region of the spine. There is evidence that the mode of failure differs depending on the location of UIV, with TL failures more likely due to fracture and UT failures more likely due to soft-tissue failures.Item Open Access Nonoperative Management in Neurologically Intact Thoracolumbar Burst Fractures: Clinical and Radiographic Outcomes.(Spine, 2016-03) Hitchon, Patrick W; Abode-Iyamah, Kingsley; Dahdaleh, Nader S; Shaffrey, Christopher; Noeller, Jennifer; He, Wenzhuan; Moritani, ToshioStudy design
Retrospective cohort study.Objective
The identification of factors that lead to the failure of nonoperative management in neurologically intact thoracolumbar burst fractures.Summary of background data
The treatment of thoracolumbar burst fractures (TLBF) can be controversial, particularly in the neurologically intact. Surgery for intact burst fractures has been advocated for early mobilization and a shorter hospital stay. These goals, however, have not always been achieved, rejuvenating an interest in nonoperative treatment.Methods
Sixty-eight neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2), and a thoracolumbar injury classification and severity score (TLICS) of 2, were treated at our institution. Based on CT scans, patients were scored based on the load-sharing classification (LSC) scale. Initial treatment consisted of bracing in clamshell thoracolumbar orthosis and gradual mobilization.Results
Owing to pain limiting mobilization, 18 patients failed nonoperative management and required instrumentation. Those who failed nonsurgical management were significantly more kyphotic (8° ± 10) and stenotic (52% ± 14%) than those successfully treated nonoperatively (3° ± 7 and 63 ± 12%, respectively). The LSC score of those undergoing surgery (6.9 ± 1.1) was also greater than those successfully treated nonoperatively (5.8 ± 1.3, P = 0.006). Length of hospitalization was longer, and hospital charges higher in those requiring surgery compared to the nonoperative group. At follow-up there was no difference between groups in the visual analog score for pain (VAS) or the Oswestry disability index.Conclusion
Owing to pain limiting mobilization, a quarter of neurologically intact patients with thoracolumbar burst fractures and a TLICS score of 2 failed nonsurgical management. The greater the kyphosis, stenosis, and fragmentation of the fracture, the more likely patients required surgery. In addition to the TLICS classification, other radiographic and clinical parameters should be included in selecting appropriate treatment strategy. The cost savings with nonoperative treatment of intact burst fractures, when appropriate, are significant.Item Open Access Progressive Spinal Kyphosis in the Aging Population.(Neurosurgery, 2015-10) Ailon, Tamir; Shaffrey, Christopher I; Lenke, Lawrence G; Harrop, James S; Smith, Justin SThoracic kyphosis tends to increase with age. Hyperkyphosis is defined as excessive curvature of the thoracic spine and may be associated with adverse health effects. Hyperkyphosis in isolation or as a component of degenerative kyphoscoliosis has important implications for the surgical management of adult spinal deformity. Our objective was to review the literature on the epidemiology, etiology, natural history, management, and outcomes of thoracic hyperkyphosis. We performed a narrative review of literature on thoracic hyperkyphosis and its implications for adult spinal deformity surgery. Hyperkyphosis has a prevalence of 20% to 40% and is more common in the geriatric population. The cause is multifactorial and involves an interaction between degenerative changes, vertebral compression fractures, muscular weakness, and altered biomechanics. It may be associated with adverse health consequences including impaired physical function, pain and disability, impaired pulmonary function, and increased mortality. Nonoperative management may slow the progression of kyphosis and improve function. Surgery is rarely performed for isolated hyperkyphosis in the elderly due to the associated risk, but is an option when kyphosis occurs in the context of significant deformity. In this scenario, increased thoracic kyphosis influences selection of fusion levels and overall surgical planning. Kyphosis is common in older individuals and is associated with adverse health effects and increased mortality. Current evidence suggests a role for nonoperative therapies in reducing kyphosis and delaying its progression. Isolated hyperkyphosis in the elderly is rarely treated surgically; however, increased thoracic kyphosis as a component of global spinal deformity has important implications for patient selection and operative planning.Item Open Access Reliability and reproducibility of subaxial cervical injury description system: a standardized nomenclature schema.(Spine, 2011-08) Bono, Christopher M; Schoenfeld, Andrew; Gupta, Giri; Harrop, James S; Anderson, Paul; Patel, Alpesh A; Dimar, John; Aarabi, Bizhan; Dailey, Andrew; Vaccaro, Alexander R; Gahr, Ralf; Shaffrey, Christopher; Anderson, David G; Rampersaud, RajStudy design
Radiographic measurement study.Objective
To develop a standardized cervical injury nomenclature system to facilitate description, communication, and classification among health care providers. The reliability and reproducibility of this system was then examined.Summary of background data
Description of subaxial cervical injuries is critical for treatment decision making and comparing scientific reports of outcomes. Despite a number of available classification systems, surgeons, and researchers continue to use descriptive nomenclature, such as "burst" and "teardrop" fractures, to describe injuries. However, there is considerable inconsistency with use of such terms in the literature.Methods
Eleven distinct injury types and associated definitions were established for the subaxial cervical spine and subsequently refined by members of the Spine Trauma Study Group. A series of 18 cases of patients with a broad spectrum of subaxial cervical spine injuries was prepared and distributed to surgeon raters. Each rater was provided with the full nomenclature document and asked to select primary and secondary injury types for each case. After receipt of the raters' first round of classifications, the cases were resorted and returned to the raters for a second round of review. Interrater and intrarater reliabilities were calculated as percent agreement and Cohen kappa (κ) values. Intrarater reliability was assessed by comparing a given rater's diagnosis from the first and second rounds.Results
Nineteen surgeons completed the first and second rounds of the study. Overall, the system demonstrated 56.4% interrater agreement and 72.8% intrarater agreement. Overall, interrater κ values demonstrated moderate agreement while intrarater κ values showed substantial agreement. Analyzed by injury types, only four (burst fractures, lateral mass fractures, flexion teardrop fractures, and anterior distraction injuries) demonstrated greater than 50% interrater agreement.Conclusion
This study demonstrated that, even in ideal circumstances, there is only moderate agreement among raters regarding cervical injury nomenclature. It is hoped that more familiarity with the proposed system will increase reproducibility in the future. Additional research is required to establish the clinical utility of this novel nomenclature schema.Item Open Access The AOSpine North America Geriatric Odontoid Fracture Mortality Study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up.(Spine, 2013-06) Chapman, Jens; Smith, Justin S; Kopjar, Branko; Vaccaro, Alexander R; Arnold, Paul; Shaffrey, Christopher I; Fehlings, Michael GSTUDY DESIGN: Retrospective, multicenter cohort study. OBJECTIVE: Assess for differences in short- and long-term mortality between operative and nonoperative treatment for elderly patients with type II odontoid fractures. SUMMARY OF BACKGROUND DATA: There is controversy regarding whether operative or nonoperative management is the best treatment for elderly patients with type II odontoid fractures. METHODS: This is a retrospective study of consecutive patients aged 65 years or older with type II odontoid fracture from 3 level I trauma centers from 2003-2009. Demographics, comorbidities, and treatment were abstracted from medical records. Mortality outcomes were obtained from medical records and a public database. Hazard ratios (HRs) and 95% confidence intervals (CI) were calculated. RESULTS: A total of 322 patients were included (mean age, 81.8 yr; range, 65.0-101.5 yr). Compared with patients treated nonoperatively (n = 157), patients treated operatively (n = 165) were slightly younger (80.4 vs. 83.2 yr, P = 0.0014), had a longer hospital (15.0 vs. 7.4 d, P < 0.001) and intensive care unit (1.5 vs. 1.1 d, P = 0.008) stay, and were more likely to receive a feeding tube (18% vs. 5%, P = 0.0003). Operative and nonoperative treatment groups had similar sex distribution (P = 0.94) and Charlson comorbidity index (P = 0.11). Within 30 days of presentation, 14% of patients died, and at maximal follow-up (average = 2.05 yr; range = 0 d-7.02 yr), 44% had died. On multivariate analysis, nonoperative treatment was associated with higher 30-day mortality (HR = 3.00, 95% CI = 1.51-5.94, P = 0.0017), after adjusting for age (HR = 1.10, 95% CI = 1.05-1.14; P < 0.0001), male sex (P = 0.69), and Charlson comorbidity index (P = 0.16). At maximal follow-up, there was a trend toward higher mortality associated with nonoperative treatment (HR = 1.35, 95% CI = 0.97-1.89, P = 0.079), after adjusting for age (HR = 1.07, 95% CI = 1.05-1.10; P < 0.0001), male sex (HR = 1.55, 95% CI = 1.10-2.16; P = 0.012), and Charlson comorbidity index (HR = 1.28, 95% CI = 1.16-1.40; P < 0.0001). CONCLUSION: Surgical treatment of type II odontoid fracture in this elderly population did not negatively impact survival, even after adjusting for age, sex, and comorbidities. The data suggest a significant 30-day survival advantage and a trend toward improved longer-term survival for operatively treated over nonoperatively treated patients. LEVEL OF EVIDENCE: 4.Item Open Access Therapeutic decision making in thoracolumbar spine trauma.(Spine, 2010-10) Oner, F Cumhur; Wood, Kirkham B; Smith, Justin S; Shaffrey, Christopher IStudy design
Systematic literature review.Objective
A systematic review was designed to answer 3 primary research questions: (1) What is the most useful classification system for surgical and nonsurgical decision-making with regard to thoracolumbar (TL) spine injuries? (2) For a TL burst fracture with incomplete neurologic deficit, what is the optimal surgical approach and stabilization technique? (3) Is complete disruption of the posterior ligamentous complex an indication for surgical intervention for TL burst fractures?Summary of background data
Despite a long history of descriptive and clinical series, there remains considerable controversy and wide variation in the treatment of traumatic TL spine injuries.Methods
A comprehensive search of the English literature was conducted using Medline and the Cochrane Database of Systematic Reviews. Standardized grading systems were used to assess the level of evidence and quality of articles impacting the research questions.Results
Recommendations for the primary research questions were as follows: (1) Thoracolumbar Injury Classification System seems to be the best system available for therapeutic decision-making for TL spine injuries (strength of recommendation: weak; quality of evidence: low). (2) There is no specific surgical approach in the case of a TL burst fracture with incomplete neurologic deficit that has any advantage with regard to neurologic recovery (strength of recommendation: weak; quality of evidence: low). (3) Complete disruption of the posterior ligamentous complex as determined collectively by morphologic criteria using plain radiographs and computed tomography is an indication for surgical intervention in TL burst fractures (strength of recommendation: strong; quality of evidence: low).Conclusion
Based on this systematic review of the literature only very low to moderate quality studies could be identified to address clinical questions related to TL spine trauma. These findings suggest the need for further study, including emphasis on higher quality studies.