The Impact of D-Dimer on Postoperative Deep Vein Thrombosis in Patients with Thoracolumbar Fracture Caused by High-Energy Injuries

Objective To investigate the dynamic variation of D-dimer and to evaluate the efficacy and accuracy of D-dimer level in patients with thoracolumbar fractures caused by high-energy injuries. Methods A total of 121 patients with thoracolumbar fractures caused by high-energy injuries were retrospectively identified and included in this study. There were 83 males and 38 females, with an average age of 48.6 ± 11.2 years. All patients were treated with either screw fixation surgery or decompression fixation surgery. The D-dimer levels were measured 1 day before surgery and on the first, third, and fifth days after surgery. The dynamic variation of D-dimer and the effects of risk factors on D-dimer levels were analysed. A receiver operating characteristic (ROC) curve analysis was performed and the appropriate D-dimer cut-off level was determined for deep vein thrombosis (DVT) screening. Results Due to a trough on the third day, D-dimer levels grew in an unsustainable manner following surgery (P < 0.001). Patients with the operation time >120 min (P = 0.009) and those with an American Spinal Injury Association (ASIA) score A-C (P < 0.001) had higher D-dimer levels. The area under the curve of D-dimer was the greatest on the third day. Applying stratified cut-off values did not change the sensitivity, specificity and negative predictive value in the group with an operation time >120 min, and ASIA score A-C group. Conclusions D-dimer levels elevated with fluctuation in patients with thoracolumbar fractures caused by high-energy injuries after surgery. Both operation time and ASIA score had an impact on D-dimer levels. Regarding DVT diagnoses, the diagnostic value of D-dimer was highest on the third day postoperatively, and stratified cut-off values by these two factors did not show better diagnostic efficacy compared with a collective one.

Clinical and Radiological Factors Affecting Thoracolumbar Fractures Outcome: WFNS Spine Committee Recommendations

To obtain a list of recommendations about clinical and radiological factors affecting outcome in thoraco-lumbar fractures with the aim of helping spine surgeons in daily practice. A systematic literature search in PubMed and Google Scholar database was done from 2010 to 2020 on the topic “thoracolumbar fracture AND radiology AND surgical outcomes” and “thoracolumbar fracture AND radiology AND surgical outcomes.” A total of 58 papers were analyzed and WFNS (World Federation of Neurosurgical Societies) Spine Committee organized 2 consensus meetings to formulate the specific recommendations the first in Peshawar in December 2019 and in a subsequent virtual meeting in June 2020 to reach an agreement. Both meetings utilized the Delphi method to analyze preliminary literature review statements based on the current evidence levels to generate recommendations through a comprehensive voting session. Eight statements were presented and reached the consensus about this topic. A variety of clinical factors is known to influence outcome of patients with thoracolumbar fractures. Some of these are well-known established factors such as blood pressure augmentation and patient age, while some are not well studied. Overall, the quality of evidence is low and we need more randomized controlled studies to validate our results. Similarly, radiological factors that can predict outcome are well stated and there is a high accordance worldwide. In reverse, still under debate is the application to choose which surgical treatment is advisable based on them.

Surgical Techniques for Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

To formulate the specific guidelines for the recommendation of thoracolumbar fracture regarding surgical techniques and nonfusion surgery. WFNS (World Federation of Neurosurgical Societies) Spine Committee organized 2 consensus meeting. For nonfusion surgery and thoracolumbar fracture, a systematic literature search in PubMed and Google Scholar database was done from 2010 to 2020. The search was further refined by excluding the articles which were duplicate, not in English or were based on animal or cadaveric subjects. After thorough shortlisting, only 50 articles were selected for full review in this consensus meeting. To generate a consensus, the levels of agreement or disagreement on each item were voted independently in a blind fashion through a Likert-type scale from 1 to 5. The consensus was achieved when the sum for disagreement or agreement was ≥ 66%. Each consensus point was clearly defined with evidence strength, recommendation grade, and consensus level provided. A magnitude of prospective papers were analyzed to formulate consensus on various surgical techniques that can be employed to address different types of thoracolumbar fractures. Surgical treatment of thoracolumbar fractures can be a better option over the nonoperative approach, especially for those who cannot tolerate months in an orthosis or cast, such as those with multiple extremity injuries, skin lesions, obesity, and so forth. It generally allows early mobilization, less hospital stay, reduced pulmonary complications, and better correction of sagittal balance. Current available literature fails to demonstrate any statistically significant benefit of fusion surgery over nonfusion in thoracolumbar fractures.

Indications for Nonsurgical Treatment of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar spine is the most injured spinal region in blunt trauma. Literature on the indications for nonoperative treatment of thoracolumbar fractures is conflicting. The purpose of this systematic review is to clarify the indications for nonsurgical treatment of thoracolumbar fractures. We conducted a systematic literature search between 2010 to 2020 on PubMed/MEDLINE, and Cochrane Central. Up-to-date literature on the indications for nonoperative treatment of thoracolumbar fractures was reviewed to reach an agreement in a consensus meeting of WFNS (World Federation of Neurosurgical Societies) Spine Committee. The statements were voted and reached a positive or negative consensus using the Delphi method. For all of the questions discussed, the literature search yielded 1,264 studies, from which 54 articles were selected for full-text review. Nine studies (4 trials, and 5 retrospective) evaluating 759 participants with thoracolumbar fractures who underwent nonoperative/surgery were included. Although, compression type and stable burst fractures can be managed conservatively, if there is major vertebral body damage, kyphotic angulation, neurological deficit, spinal canal compromise, surgery may be indicated. AO type B, C fractures are preferably treated surgically. Future research is necessary to tackle the relative paucity of evidence pertaining to patients with thoracolumbar fractures.

Inclusion of the fractured level into the construct of short segment fixation in patients with thoracolumbar fractures: clinical and radiological outcome

Background Thoracolumbar fractures represent a widespread injuries that can cause significant disability and strain the healthcare system. Different surgical approaches are described in the literature. This study was conducted to evaluate the fractured level inclusion in short-segment fixation of thoracolumbar junction spine fractures. Results Preoperative neurological deficit was reported in seven patients ranging from ASIA grade C to D. All of these patients improved to grade E by the end of the follow-up period, except for one patient who improved from grade C to D. The mean Oswestry Disability Index was 19.87%. The mean postoperative Cobb angle was 11.77° which significantly improved compared to a preoperative value of 19.37°. There was a significant improvement in the postoperative anterior and posterior vertebral body height compared to the preoperative values. The vertebral body compression ratio significantly improved during the postoperative period to a mean of 84% compared to 76% preoperative. Conclusions There was significant improvement of the postoperative values of the mean Cobb angle, the anterior and the posterior vertebral body height as well as the vertebral body compression ratio compared to the preoperative values.

Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary?

Background While several studies report on accuracy rates of pedicle screws, risk factors associated with inaccurate pedicle screw positioning in patients with thoracolumbar fractures are reported rarely. CT scan as a routine postoperative control is advocated by various authors, however its necessity remains unclear. Methods Two hundred forty-five patients were included in this retrospective study. Percutaneous dorsal instrumentation was most commonly performed (n = 201). Classification of Zdichavsky et al. and Rao et al. were used to classify screw misplacement and anterior perforation was further evaluated according to the extent of perforation (< 2 mm; > 2 mm). Multivariate analysis was performed to identify risk factors for misplacement of screws. Results One thousand sixty-eight pedicle screws were inserted in 245 patients. Misplacement was found in 51 screws (4.8%) in 42 patients (17.1%) according to the classification of Zdichavsky et al. and in 75 screws (7.0%) in 64 patients (26.1%) according to the classification of Rao et al.. An anterior perforation of the vertebral cortex was found in 56 screws (5.2%). Multivariate analysis showed fracture location in the upper thoracic (p = 0.048) and lumbar spine (p = 0.013) to be the only independent predictors for screw misplacement. In addition a significant correlation between pedicle diameter and the occurrence of screw malposition was found (p = 0.003). No consequences were drawn from postoperative routine CT in asymptomatic patients. Conclusion An overall low rate of screw misplacement was found with fracture location in the upper thoracic and lumbar spine being the only factors independently associated with the risk of screw misplacement. No consequences were drawn from postoperative routine CT in asymptomatic patients. Therefore its use has to be discussed critically.

How Often MRI Would Change the Fracture Classification or Decision-making in Thoracolumbar Fractures Compared to CT Alone?

Introduction: This study aimed at analyzing the frequency and predictor of the change in classification of TLFs after performing MRI compared with CT alone. Methodology: This retrospective review included 235 consecutive patients with acute TLFs (T1-L5) who presented at a single level-1 trauma center between 2014 and 2021 and underwent both CT and MRI. Patients with translation injury, neurologic deficit, or osteoporotic fracture were excluded. Three reviewers independently classified all fractures according to AOSpine and Thoracolumbar Injury classification (TLISS) by CT and then MRI. A fourth reviewer only looked at the MRI images. Posterior ligamentous complex Injury was diagnosed on CT and MRI by two positive CT findings and black stripe discontinuity. Mc-Nemar test was used to evaluate the difference in the proportions of AO type A and B. Result: The AO classification by CT was type A in 181 patients (77%) and type B in 54 patients (23%). The addition of MRI after CT changed AO classification in 25/235 patients (10.6%, P < 0.0001) due to an 8.5% (20/235) upgrade from type A to type B and 2.1% (5/235) downgrade from type B to type A. When PLC injury in CT was defined by one positive CT finding and in MRI by high signal intensity, it significantly increased the rate of fracture reclassification by MRI compared to default analysis (22% and 33% vs 11%, respectively; P < 0.0001). The best predictor of upgrade from type A to type B and downgrade from type B to type A was a single positive CT finding, and the presence of only two CT signs as opposed to three signs, respectively (reclassification rate 26% vs 4.6%, P < 0.0001 and 17% vs 0%, P = 0.03, respectively). Thoracic and thoracolumbar fractures showed a significantly higher reclassification rate than low lumbar (20% and 10% vs 0%, respectively, P = 0.07). Conclusion: Using appropriate CT/MRI criteria of PLC injury, the rate of fracture reclassification by MRI can be as low as 10%. The use of alternative CT/MRI criteria or inaccurate image interpretation could significantly increase the rate of fracture reclassification up to 20–30%. The rate of change of fracture classification by MRI could be predicted by the number of positive CT findings on CT or fracture level.