Restricted cement augmentation in unstable geriatric midthoracic fractures treated by long-segmental posterior stabilization leads to a comparable construct stability

The goal of this study is to compare the construct stability of long segmental dorsal stabilization in unstable midthoracic osteoporotic fractures with complete pedicle screw cement augmentation (ComPSCA) versus restricted pedicle screw cement augmentation (ResPSCA) of the most cranial and caudal pedicle screws under cyclic loading. Twelve fresh frozen human cadaveric specimens (Th4–Th10) from individuals aged 65 years and older were tested in a biomechanical cadaver study. All specimens received a DEXA scan and computer tomography (CT) scan prior to testing. All specimens were matched into pairs. These pairs were randomized into the ComPSCA group and ResPSCA group. An unstable Th7 fracture was simulated. Periodic bending in flexion direction with a torque of 2.5 Nm and 25,000 cycles was applied. Markers were applied to the vertebral bodies to measure segmental movement. After testing, a CT scan of all specimens was performed. The mean age of the specimens was 87.8 years (range 74–101). The mean T-score was − 3.6 (range − 1.2 to − 5.3). Implant failure was visible in three specimens, two of the ComPSCA group and one of the ResPSCA group, affecting only one pedicle screw in each case. Slightly higher segmental movement could be evaluated in these three specimens. No further statistically significant differences were observed between the study groups. The construct stability under cyclic loading in flexion direction of long segmental posterior stabilization of an unstable osteoporotic midthoracic fracture using ResPSCA seems to be comparable to ComPSCA.

Spinal Manifestation of Malignant Primary (PLB) and Secondary Bone Lymphoma (SLB)

Manifestation of malignant lymphoma in the spine is rare; there have only been a few cases reported in the literature. Due to its rarity, there is no gold standard for the management of patients suffering from spinal lymphoma manifestations. Methods: We retrospectively reviewed the data for 37 patients (14 female, 23 male) with malignant lymphoma in the spine receiving intervention in our center from March 2006 until June 2020. Neurological impairment, pain, diagnostics, and/or surgical instability were the criteria for surgery in this patient cohort. Otherwise, only CT-guided biopsies were conducted. Analysis of the patient cohort was based on the Karnofsky performance status scale (KPSS), location of the lesion, spinal levels involved, spinal instability neoplastic score (SINS), surgical treatment, histopathological workup, adjuvant therapy, and overall survival. The following surgical procedures were performed: posterior stabilization and decompression in nine patients; decompression and/or tumor debulking in 18 patients; a two-staged procedure with dorsal stabilization and vertebral body replacement in four patients; decompression and biopsy in one patient; a two-stage procedure with kyphoplasty and posterior stabilization for one patient; posterior stabilization without decompression for one patient; a vertebroplasty and cement-augmented posterior stabilization for one patient; and a CT-guided biopsy alone for two patients. Twenty-one patients (56.78%) had ≥1 lesion in the thoracic spine, 10 patients (27.03%) had lesions in the lumbar spine, two patients had lesions in the cervicothoracic junction, two patients had lesions in the thoracolumbar junction, one patient had a lesion in the lumbosacral junction, and one patient had a lesion in the sacrum. The diagnoses of the histopathological workup were diffuse large B-cell lymphoma in 23 (62.16%) cases, indolent lymphoma in 11 (29.74%) cases, anaplastic T-cell lymphoma in one case (2.70%), T-cell lymphoma in one case (2.70%), and Burkitt lymphoma in one (2.70%) case. The median overall survival was 7.2 months (range 0.1–266.7 months). Pre- and postoperative KPSS scores were 70% (IQR 60–80%). Manifestation of malignant lymphomas in the spine is rare. Similar to the approach taken for spine metastases, a surgical intervention in cases of neurological impairment or manifest or potential instability is indicated, followed by chemoimmunotherapy and radiotherapy.

Morbidity and Mortality in Patients over 90 Years of Age Following Posterior Stabilization for Acute Traumatic Odontoid Type II Fractures: A Retrospective Study with a Mean Follow-Up of Three Years

Odontoid type II fractures represent the most common cervical spine injuries in the elderly. The decision for surgical treatment in very elderly patients is still controversial. The aim of this study was to assess morbidity and mortality in patients over 90 years of age undergoing CT-guided posterior stabilization for unstable odontoid type II fractures. A total of 15 patients with an acute traumatic odontoid type II fracture who received surgical treatment for unstable odontoid type II fractures were retrospectively analyzed. Complications, morbidity, and mortality as well as length of ICU and hospital stay were determined. Clinical follow-up evaluation was based on outpatient presentation and information from family members and general practitioners. Finally, we conducted a comparison of complications rates between patients over 90 years of age and patients between 65 and 89 years old with a type II odontoid fracture after CT-guided posterior stabilization in our institution. The mean age was 91.4 years. Patients were predominately female (87%). In-hospital deaths did not occur. The average length of the hospital stay was 13.4 days and 1.9 days for the ICU. Blood transfusion was necessary in two patients (13%). Two patients (13%) developed urinary tract infection, one patient (7%) a delirium, and another epistaxis (7%). One patient (7%) developed pneumonic sepsis and fully recovered within several weeks. The mean follow-up was 36 months (range 9–72 months). Implant-related complications developed in one patient (7%). Five patients died during the follow-up period, with an average time to death of 26.6 months. Postoperative bracing was not needed in any of the patients. Posterior stabilization of unstable odontoid fractures type II using CT-guided navigation in patients over 90 years of age is a safe and effective procedure with low complications and mortality rates.

Clinical Outcome of Single-Stage Decompression and Posterior Stabilization in Thoracolumbar Spinal Tuberculosis

Background Thoracolumbar spine constitutes the most common site for spinal tuberculosis. Though the treatment of spinal tuberculosis is antitubercular drugs initially, the patient with neurologic weakness warrants definitive surgical procedure of decompression and stabilization. Even though many investigators have reported favorable results with anterior decompression and stabilization surgery, due to the increased morbidity and complications, the posterior-only approach with decompression and stabilization has evolved as the operation of choice in recent time. Methods All patients aged between 18 and 70 years with clinically and radiologically proven symptomatic thoracolumbar spinal tuberculosis who failed with conservative treatment for 4 weeks or developed neurologic weakness between the treatments are included in this study. All patients were offered decompression and posterior stabilization with transpedicular screws and rods after explaining the above procedure. Clinical outcome was measured by modified Frankel grading; AIS (American Spinal Injury Association impairment score) grade impairment score; and pain assessment done with visual analog scale (VAS) pre- and postoperatively and at 3, 6, and 9 months of interval. Results The postoperative pain relief, neurologic improvement as per modified Frankel grade, AIS grade, and improvement in erythrocyte sedimentation rate and C-reactive protein were significant as compared with the preoperative status. The surgical interventions thus prove to have adequate relief to the patient and arresting the disease progression. The surgical outcome has very minimal intra- and postoperative complications. Conclusion Single-stage decompression and posterior stabilization in thoracolumbar spinal tuberculosis is safe, effective, and results in good clinical outcome. The advantages of surgery include thorough debridement, decompression, and achievement of spinal stabilization.

Midterm outcome after posterior stabilization of unstable Midthoracic spine fractures in the elderly

Background The evidence for the treatment of midthoracic fractures in elderly patients is weak. The aim of this study was to evaluate midterm results after posterior stabilization of unstable midthoracic fractures in the elderly. Methods Retrospectively, all patients aged ≥65 suffering from an acute unstable midthoracic fracture treated with posterior stabilization were included. Trauma mechanism, ASA score, concomitant injuries, ODI score and radiographic loss of reduction were evaluated. Posterior stabilization strategy was divided into short-segmental stabilization and long-segmental stabilization. Results Fifty-nine patients (76.9 ± 6.3 years; 51% female) were included. The fracture was caused by a low-energy trauma mechanism in 22 patients (35.6%). Twenty-one patients died during the follow-up period (35.6%). Remaining patients (n = 38) were followed up after a mean of 60 months. Patients who died were significantly older (p = 0.01) and had significantly higher ASA scores (p = 0.02). Adjacent thoracic cage fractures had no effect on mortality or outcome scores. A total of 12 sequential vertebral fractures occurred (35.3%). The mean ODI at the latest follow up was 31.3 ± 24.7, the mean regional sagittal loss of reduction was 5.1° (± 4.0). Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral fractures during follow-up (p = 0.03). Conclusion Unstable fractures of the midthoracic spine are associated with high rates of thoracic cage injuries. The mortality rate was rather high. The majority of the survivors had minimal to moderate disabilities. Thereby, patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up.

A Rare Case of Contiguous Three-level Lumbar Burst Fractures-treated with Combined Posterior Stabilization and Anterior Fusion

Introduction: Burst fractures occur frequently in high energy trauma and are commonly associated with falls from height and road traffic accidents. While multiple burst fractures are not uncommon in thoracic spine, three or more contiguous level burst fractures are a relative rarity especially, in lumbar spine. The treatment of multilevel burst fractures must be individualized, and each fracture should be treated according to its inherent stability. To the best of our knowledge, this is the only case of such injury reported in English literature. Case Report: A 17-year-old girl who sustained contiguous three-level lumbar burst fractures with neurological compromise following alleged history of fall from height. Radiographs/computed tomography scan revealed burst fractures of L2, L3, and L4 vertebrae with retropulsion of bony fragments at all the levels. Patient underwent minimally invasive posterior stabilization and anterior Hemi-corpectomy of L2, L4, and fusion. The patient recovered completely from neurological deficits by the end of 6 months. Conclusion: Multiple contiguous burst fractures in the lumbar spine are a rare entity. To the best of our knowledge, this is the only case of such injury reported in English literature. The treatment requires a thorough assessment of the fracture pattern and often requires a combination of surgical approaches. Each fracture merits treatment based on individual characteristics of fracture patterns and the amount of canal compromise at each level. Keywords: Lumbar, burst fracture, multiple, contiguous.