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Objectives: Percutaneous vertebroplasty and kyphoplasty are common interventions for osteoporotic vertebral compression fractures. However, there is concern about an increased risk of adjacent-level fractures after treatment. This study aimed to compare the risk of adjacent-level fractures after vertebroplasty and kyphoplasty with the natural history after osteoporotic vertebral compression fractures., Materials and Methods: A network meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to the natural history after osteoporotic vertebral compression fractures. Frequentist network meta-analysis was conducted using the "netmeta" package, and heterogeneity was assessed using Q statistics. The pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using random effects., Results: Twenty-three RCTs with a total of 2838 patients were included in the analysis. The network meta-analysis showed comparable risks of adjacent-level fractures between vertebroplasty, kyphoplasty, and natural history after osteoporotic vertebral compression fractures with a mean follow-up of 21.2 (range: 3-49.4 months). The pooled RR for adjacent-level fractures after kyphoplasty compared to natural history was 1.35 (95% CI, 0.78-2.34, p = 0.23) and for vertebroplasty compared to natural history was 1.16 (95% CI, 0.62-2.14) p = 0.51. The risk of bias assessment showed a low to moderate risk of bias among included RCTs., Conclusion: There was no difference in the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to natural history after osteoporotic vertebral compression fractures. The inclusion of a large patient number and network meta-analysis of RCTs serve evidence-based clinical practice., Clinical Relevance Statement: The risk of adjacent-level fracture following percutaneous vertebroplasty or kyphoplasty is similar to that observed in the natural history after osteoporotic vertebral compression fractures., Key Points: RCTs have examined the risk of adjacent-level fracture after intervention for osteoporotic vertebral compression fractures. There was no difference between vertebroplasty and kyphoplasty patients compared to the natural disease history for adjacent compression fractures. This is strong evidence that interventional treatments for these fractures do not increase the risk of adjacent fractures., (© 2024. The Author(s), under exclusive licence to European Society of Radiology.)

Low bone mineral density (BMD) can predispose to vertebral body compression fractures and postoperative instrumentation failure. DEXA is considered the gold standard for measurement of BMD, however it is not obtained for all spine surgery patients preoperatively. There is a growing body of evidence suggesting that more routinely acquired spine imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) can be opportunistically used to measure BMD. Here we review available studies that assess the validity of opportunistic screening with CT-derived Hounsfield Units (HU) and MRI-derived vertebral vone quality (VBQ) to measure BMD of the spine as well the utility of these measures in predicting postoperative outcomes. Additionally, we provide screening thresholds based on HU and VBQ for prediction of osteopenia/ osteoporosis and postoperative outcomes such as cage subsidence, screw loosening, proximal junctional kyphosis, and implant failure., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Both ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) cause a rigid spine, but through different pathophysiology. Recent data has shown that characteristic fracture patterns may also differ following trauma since the posterior osseous and soft tissue elements are often spared in DISH. CT and MRI are important in diagnosing spine injury, but given the differences between AS and DISH, the utility of obtaining both studies in all patients warrants scrutiny., Purpose: To assess the prevalence of posterior element injury on CT and MRI in DISH and AS patients with known vertebral body injury detected on CT; to determine whether MRI demonstrates additional injuries in neurologically intact patients presumed to have isolated vertebral body injuries on CT., Study Design: Multicenter, retrospective, case-control study., Patient Sample: DISH and AS patients presenting after spine trauma between 2007 and 2017., Outcome Measures: Review of CT and MRI findings at the time of presentation., Methods: One hundred sixty DISH and 85 AS patients presenting after spine trauma were identified from 2 affiliated academic hospitals serving as level 1 trauma and tertiary referral centers. A diagnosis of DISH or AS was verified by a board-certified emergency radiologist with 3 years of experience. Age, gender, mechanism of injury, fracture type, spine CT and MRI imaging findings, surgical intervention, and neurologic deficit were recorded. The CT and MRI studies were reviewed by the same radiologist for fracture location and type using the AO spine classification. No funding source or conflict of interest was present., Results: Median age was 72 and 79 years old for the AS and DISH groups, respectively. Both were predominantly male (81%) and most presented after a low energy mechanism of injury (74% and 73%). Type C AO spine injuries were seen in 52% of AS patients but only 4% of DISH patients. In patients with known vertebral body injury on CT, additional injury to the posterior elements on CT or MRI in DISH patients was 51% versus 92% in AS patients. However, in patients with an isolated vertebral body fracture on CT and no neurological deficit, MRI identified posterior element injury in only 4/22 (18%) DISH patients compared to 5 of 7 (71%) AS patients. None of the MRI findings in the DISH patients were considered clinically important while all 5 AS patients eventually underwent operative treatment despite having no neurological deficit. Epidural hematoma on MRI was seen in 43% of AS patients as opposed to 5% of DISH patients., Conclusion: Based on our small sample size, CT alone may be adequate in DISH patients with isolated vertebral body fractures and no neurologic deficit, but an additional MRI should be considered in the presence of an unclear neurological exam or deficit. MRI should be strongly considered for any AS patient regardless of neurologic status., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The biomechanical stability of the spine is altered in patients with a rigid spine, rendering it vulnerable to fracture even from relatively minor impact. The rigid spine entities are ankylosing spondylitis (AS), diffuse idiopathic skeletal hyperostosis, degenerative spondylosis, and a surgically fused spine. The most common mechanism of injury resulting in fracture is hyperextension, which often leads to unstable injury in patients with a rigid spine per the recent AOSpine classification system. Due to the increased risk of spinal fractures in this population, performing a spine CT is the first step when a patient with a rigid spine presents with new back pain or suspected spinal trauma. In addition, there should be a low threshold for performing a non-contrast-enhanced spine MRI in patients with a rigid spine, especially those with AS who may have an occult fracture, epidural hematoma, or spinal cord injury. Unfortunately, owing to insufficient imaging and an unfamiliarity with fracture patterns in the setting of a rigid spine, fracture diagnosis is often delayed, leading to significant morbidity and even death. The radiologist's role is to recognize the imaging features of a rigid spine, identify any fractures at CT and MRI, and fully characterize the extent of injury. Reasons for surgical intervention include neurologic deficit or concern for deterioration, an unstable fracture, or the presence of an epidural hematoma. By understanding the imaging features of various rigid spine conditions and vigilantly examining images for occult fractures, the radiologist can avoid a missed or delayed diagnosis of an injured rigid spine. © RSNA, 2019.

Purpose: To assess whether a focused magnetic resonance imaging (MRI) limited to the region of known acute traumatic thoracic or lumbar fracture(s) would miss any clinically significant injuries that would change patient management., Study Design/setting: A multicenter retrospective clinical study., Patient Sample: Adult patients with acute traumatic thoracic and/or lumbar spine fracture(s)., Outcome Measures: Pathology identified on MRI (ligamentous disruption, epidural hematoma, and cord contusion), outside of the focused zone, an alteration in patient management, including surgical and nonsurgical, as a result of the identified pathology outside the focused zone., Methods: Records were reviewed for all adult trauma patients who presented to the emergency department between 2008 and 2016 with one or more fracture(s) of the thoracic and/or lumbar spine identified on computed tomography (CT) and who underwent MRI of the entire thoracic and lumbar spine within 10 days. Exclusion criteria were patients with >4 fractured levels, pathologic fractures, isolated transverse, and/or spinous process fractures, prior vertebral augmentation, and prior thoracic or lumbar spine instrumentation. Patients with neurologic deficits or cervical spine fractures were also included. MRIs were reviewed independently by one spine surgeon and one musculoskeletal fellowship-trained emergency radiologist for posterior ligamentous complex (PLC) integrity, vertebral injury, epidural hematoma, and cord contusion. The surgeon also commented on the clinical significance of the pathology identified outside the focused zone. All cases in which pathology was identified outside of the focused zone (three levels above and below the fractures) were independently reviewed by a second spine surgeon to determine whether the pathology was clinically significant and would alter the treatment plan., Results: In total, 126 patients with 216 fractures identified on CT were included, with a median age of 49 years. There were 81 males (64%). Sixty-two (49%) patients had isolated thoracolumbar junction injuries and 36 (29%) had injuries limited to a single fractured level. Forty-seven (37%) patients were managed operatively. PLC injury was identified by both readers in 36 (29%) patients with a percent agreement of 96% and κ coefficient of 0.91 (95% CI 0.87-0.95). Both readers independently agreed that there was no pathology identified on the complete thoracic and lumbar spine MRIs outside the focused zone in 107 (85%) patients. Injury outside the focused zone was identified by at least one reader in 19 (15%) patients. None of the readers identified PLC injury, cord edema, or noncontiguous epidural hematoma outside the focused zone. Percent agreement for outside pathology between the two readers was 92% with a κ coefficient of 0.60 (95% CI 0.48-0.72). The two spine surgeons independently agreed that none of the identified pathology outside of the focused zone altered management., Conclusions: A focused MRI protocol of three levels above and below known thoracolumbar spine fractures would have missed radiological abnormality in 15% of patients. However, the pathology, such as vertebral body edema not appreciated on CT, was not clinically significant and did not alter patient care. Based on these findings, the investigators conclude that a focused protocol would decrease the imaging time while providing the information of the injured segment with minimal risk of missing any clinically significant injuries., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: This study aims to determine whether secondary CT findings can predict posterior ligament complex (PLC) injury in patients with acute thoracic (T) or lumbar (L) spine fractures., Methods: This is a retrospective study of 105 patients with acute thoracic and lumbar spine fractures on CT, with MRI as the reference standard for PLC injury. Three readers graded CT for facet joint alignment (FJA), widening (FJW), pedicle or lamina fracture (PLF), spinous fracture (SPF), interspinous widening (ISW), vertebral translation (VBT), and posterior endplate fracture (PEF). Univariate and multivariate logistic regression analyses were performed separately for each reader to test for associations between CT and PLC injury, and diagnostic performance of CT was calculated., Results: Fifty-three of 105 patients had PLC injury by MRI. Statistically significant predictors of PLC injury were VBT, PLF, ISW, and SPF. Using these four CT findings, odds of PLC injury ranged from 3.8 to 5.6 for one positive finding, but increased to 13.6-25.1 for two or more. At least one positive CT finding was found to yield average sensitivity of 82% and specificity 59%, while two or more yielded sensitivity 46% and specificity 88%., Conclusion: While no individual CT finding is sufficiently accurate to diagnose or exclude PLC injury, greater the number of positive CT findings (VBT, PLF, ISW, and SPF), the higher the odds of PLC injury. The presence of a single abnormal CT finding may warrant confirmatory MRI for PLC injury, while two or more CT findings may have adequate specificity to avoid need for MRI prior to surgical intervention. These slides can be retrieved under Electronic Supplementary Material.

Background: The influence of non-white race on outcomes following orthopedic injury has been described in the past. The impact of such factors on hospital processes and quality of care after spinal trauma is less well understood., Study Design: A cohort control study using the Massachusetts Statewide Inpatient Dataset (2003-2010) was used as the study design., Purpose: This study aimed to determine whether (1) hospital processes and quality of care associated with the treatment of cervical spine fractures was significantly altered by non-white race and (2) whether findings were different among those treated at academic medical centers (AMCs)., Sample: The study comprised 10,841 patients., Outcomes: Surgical rate, postoperative morbidity, mortality, and length of stay (LOS) were the outcome measures., Methods: Baseline differences between cohorts were evaluated using chi-square or Wilcoxon rank sum tests. Logistic and negative binomial regression techniques were used to adjust for confounders, including whether a surgical intervention was performed. Subset analyses were performed to evaluate whether findings were different for individuals treated at AMCs., Results: The rate of surgical intervention was not significantly different between non-whites and whites (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.82-1.04). LOS (regression coefficient [RC] 0.18, 95% CI 0.13-0.23), mortality (OR 1.49, 95% CI 1.20-1.85), and complications (OR 1.17, 95% CI 1.02-1.33) were significantly increased among non-white patients. These findings were largely preserved among those treated at AMCs., Conclusions: Our results reinforce the fact that efforts at universal access to care may be insufficient to reduce differences in care among minority patients following cervical trauma. Future mixed-methods research is necessary to more effectively evaluate the etiologies behind health-care disparities associated with race in different health-care environments., Level of Evidence: The level of evidence is Level III, prognostic study., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: There is a substantial concern among spine surgeons that healthcare reform efforts will alter the processes through which spinal care is delivered and decrease overall quality. We used the Statewide Inpatient Dataset for Massachusetts to evaluate changes in hospital processes and quality of care for patients with cervical fractures following the implementation of health reform., Methods: This was a pre-post retrospective analysis of patients (n=9,387) treated for cervical fractures in Massachusetts between 2003-2006 and 2008-2010. Changes in hospital processes (surgical intervention, length of stay (LOS) and environment of care) and quality of care (mortality, complications, reoperation and failure to rescue (FTR)) were the outcomes of interest. FTR is a quality measure that evaluates a hospital's capacity to avoid mortality following the occurrence of a sentinel complication. Patients treated between 2003 and 2006 were considered the pre-reform group. The post-reform cohort consisted of those treated from 2008 to 2010. Baseline differences between cohorts were evaluated using chi-square or Mann-Whitney U tests. Unadjusted comparisons between the dependent variables and the onset of healthcare reform were performed, followed by regression techniques that adjusted for differences in case-mix and whether a surgical intervention was performed. Multivariable logistic regression was used for categorical variables and negative binomial regression was employed for continuous variables., Results: The rates of surgical intervention remained unchanged pre- and post-reform (p=0.25). Hospital length of stay (RC: -0.18, 95% CI: -0.22, -0.14) and the FTR rate following surveillance insensitive complications (OR: 0.49, 95% CI: 0.25, 0.94) were significantly reduced following health reform. Post-reform, academic centers experienced a 22% reduction in mortality (95% CI: 0.61, 0.99) a 40% decrease in FTR (95% CI: 0.40, 0.89), a 30% decrease in surveillance insensitive complications (95% CI: 0.51, 0.96) and a 67% reduction in FTR after surveillance insensitive morbidity (95% CI: 0.11, 0.94)., Conclusions: In the period following Massachusetts healthcare reform, significant improvements were noted in hospital process and quality measures around the care of patients with cervical spine fractures. Such findings were particularly robust among academic centers. These results may forecast changes in the delivery of spine surgical care following other health reform initiatives. Level of Evidence III., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Studies comparing operative with nonoperative treatment of a stable burst fracture of the thoracolumbar junction in neurologically intact patients have not shown a meaningful difference at early follow-up. To our knowledge, longer-term outcome data have not before been presented., Methods: From 1992 to 1998, forty-seven consecutive patients with a stable thoracolumbar burst fracture and no neurological deficit were evaluated and randomized to one of two treatment groups: operative treatment (posterior or anterior arthrodesis) or nonoperative treatment (a body cast or orthosis). We previously reported the results of follow-up at an average of forty-four months. The current study presents the results of long-term follow-up, at an average of eighteen years (range, sixteen to twenty-two years). As in the earlier study, patients at long-term follow-up indicated the degree of pain on a visual analog scale and completed the Roland and Morris disability questionnaire, the Oswestry Disability Index (ODI) questionnaire, and the Short Form-36 (SF-36) health survey. Work and health status were obtained, and patients were evaluated radiographically., Results: Of the original operatively treated group of twenty-four patients, follow-up data were obtained for nineteen; one patient had died, and four could not be located. Of the original nonoperatively treated group of twenty-three patients, data were obtained for eighteen; two patients had died, and three could not be located. The average kyphosis was not significantly different between the two groups (13° for those who received operative treatment compared with 19° for those treated nonoperatively). Median scores for pain (4 cm for the operative group and 1.5 cm for the nonoperative group; p = 0.003), ODI scores (20 for the operative group and 2 for the nonoperative group; p <0.001) and Roland and Morris scores (7 for the operative group and 1 for the nonoperative group; p = 0.001) were all significantly better in the group treated nonoperatively. Seven of eight SF-36 scores also favored nonoperative treatment., Conclusions: While early analysis (four years) revealed few significant differences between the two groups, at long-term follow-up (sixteen to twenty-two years), those with a stable burst fracture who were treated nonoperatively reported less pain and better function compared with those who were treated surgically., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Study 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.

Study Design: Retrospective cohort study., Objective: To determine the influence of age, comorbidities, and treatment type on mortality in elderly patients with acute Type II odontoid fractures., Summary of Background Data: Prior studies have documented increased morbidity and mortality among geriatric patients sustaining odontoid fractures. However, there is limited data regarding the effect of patient age, medical comorbidities, and treatment selection on mortality after Type II odontoid (C2) fractures in the elderly., Methods: An institutional registry was used to identify all Type II odontoid fractures sustained by patients aged 65 and older from 1991 to 2006. Demographic information, date of injury, associated injuries, treatment type, and comorbidities were abstracted from medical records. Mortality was ascertained using the National Death Index. Risks of mortality and their associated 95% confidence intervals (CIs) were calculated at 3 months, 1 year, 2 years, and 3 years. Multivariable Cox proportional hazard regression was used to evaluate independent factors affecting mortality stratified by age (65-74 years, 75-84 years, ≥ 85 years) and treatment type (operative or nonoperative treatment, and halo or collar immobilization)., Results: Of 156 patients identified with Type II odontoid fracture, the average age was 82 years (SD = 7.8; Range: 65-101). One hundred and twelve patients (72%) were treated nonoperatively. At 3 years postinjury, there was a 39% (95% CI: 32-47) mortality rate for the entire cohort. Mortality for the operative group was 11% (95% CI: 2-21) at 3 months and 21% (95% CI: 9-32) at 1 year compared with 25% (95% CI: 17-33) at 3 months and 36% (95% CI: 27-45) at 1 year in the nonoperative group. The Cox regression model showed that the protective effect of surgery was seen in patients aged 65 to 74 years, in whom the hazard ratio associated with surgery for mortality after odontoid fracture was 0.4 (95% CI: 0.1-1.5). Those aged 75 to 84 years had a hazard ratio of 0.8 (95% CI: 0.3-2.3), and patients 85 years or older had a hazard ratio of 1.9 (95% CI: 0.6-6.1; P value for interaction between age and treatment = 0.09) with operative treatment having a protective effect in patients aged 65 to 74 years., Conclusion: In a cohort of elderly patients, Type II odontoid fractures were associated with a high rate of mortality, regardless of intervention.

Background Context: Several reports indicate that patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) have increased mortality after cervical spine fractures. However, outcomes of the fractured hyperostotic cervical spine are incompletely described, and there are limited data regarding the covariable effects of patient age and medical comorbidities on mortality., Purpose: To determine mortality associated with cervical fractures in patients with hyperostotic disease., Study Design: Retrospective case-control study., Patient Sample: Forty-three patients identified through a registry as having fractures of the cervical spine in the setting of hyperostotic disease. These patients were matched to 43 controls who did not carry the diagnosis of hyperostotic disease., Outcome Measures: Mortality at 3 months and 1, 2, and 3 years after fracture., Methods: An institutional database was used to identify all cervical fractures sustained by patients aged 65 years and older from 1991 to 2006. Demographic information, date of injury, associated injuries, treatment type, presence of AS or DISH, and comorbidities were abstracted from medical records and radiographs. Mortality was ascertained using the National Death Index. Patients with AS or DISH were matched to controls who did not carry the diagnosis of hyperostotic disease. Risks of mortality were calculated at 3 months, 1 year, 2 years, and 3 years. Kaplan-Meier methods, logistic regression analysis, the two independent sample t test, and the Fisher exact test were used to compare mortalities between the two groups. Statistical significance was determined as p values <.05., Results: Forty-three patients were identified as having fractures in the setting of hyperostotic disease of the cervical spine. Twenty-seven individuals had DISH, and 16 had AS. The average age of both the study group and controls was 80 years, with an age range of 68 to 94. There was no significantly increased risk of mortality between the overall study group and control group at 3 months (p=.20), 1 (p=.22), 2 (p=.15), or 3 years (p=.50) after injury. Compared with controls, subgroup analysis of patients with AS showed a statistically increased risk of mortality at 3 months (p<.01) and at 1 and 2 years (p<.01 at both time points). When compared with individuals with DISH, those with AS had an increased risk of mortality at time points up to 2 years after fracture. Patients with DISH did not have an increased mortality risk at any time point when compared with controls., Conclusions: The effect of fracture on mortality appears to be greatest in those with AS. Patients with DISH did not demonstrate an increased risk of mortality compared with age- and sex-matched controls. Future studies of patients with hyperostotic disease should analyze patients with DISH and AS separately instead of as a single homogenous group., Level of Evidence: Level IV., (Published by Elsevier Inc.)

Introduction: Although outcome instruments have been used extensively in spine surgical research, few studies at present specifically address their use in investigations regarding spine trauma. In this review we provide a summary of the outcome instruments used most frequently in spine trauma research, identify the unique challenges of studying outcomes of spine trauma patients, and propose an integrated approach that may be beneficial for future studies., Methods: We reviewed the use of outcome instruments applicable to spine trauma research, including generic health measures, inventories of back-specific function, pain scales, health related quality of life (HRQOL) instruments, and radiographic determinants of outcome., Results: Several inventories have been utilised to measure clinical outcomes following spinal trauma. Excluding measures of neurological function (e.g. ASIA motor score), none have been specifically validated for use with spine fractures. The SF-36, RMDQ, and ODI are amongst the most commonly used instruments. Importantly, the use of validated functional outcome measures in spine trauma research is hampered by the fact that the pre-morbid state of patients who sustain spine trauma may not be accurately represented by normative values established for the general population. The VAS is used most frequently to assess degree of neck and back pain. Most studies have relied on non-validated measures to determine radiographic results of treatment, although more elegant radiographic metrics exist., Conclusions: Functional outcome measurement of traumatically injured spine patients is challenging because available generic and spine-specific instruments were not designed for or validated in this population. Furthermore, no single inventory is capable of capturing global data necessary to evaluate results following these injuries. Investigations seeking to quantify outcomes following spine trauma should consider the use of a combination of existing surveys in a complementary fashion that should include a generic health survey, a measure of back-specific function, and determinants of bodily pain and work-related disability., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Study Design: Radiographic measurement study., Objectives: To assess the inter- and intraobserver reliability of angulation and displacement measurements for odontoid fractures and traumatic spondylolistheses (Hangman fractures) of C2, and to compare the reliability of measurements made on computerized tomography (CT) versus those made using plain radiographs., Summary of Background Data: Measurements of various parameters of C2 injuries can influence treatment decision making. However, there is a paucity of data regarding the reproducibility of these measurements., Methods: A series of 19 cases, representing 10 odontoid fractures and 9 Hangman fractures, were prepared and distributed to surgeon raters on 2 occasions. Each rater was provided with a pictorial diagram illustrating the prescribed measurement technique(s). For odontoid fractures, raters were asked to measure angulation, translation, atlanto-dens interval (ADI), and posterior ADI. For Hangman fractures, angulation and C2-C3 translation were assessed. Measurements were made using plain films and CT images. Reliability was reflected by calculation of intraclass correlation coefficients and Pearson correlation coefficients., Results: Intrarater analysis for both odontoid and Hangman fractures demonstrated high reproducibility. Interobserver evaluation showed that the posterior ADI was the most reproducible method, whereas all other measurements for odontoid fractures were found to have poor reproducibility. For Hangman fractures, the endplate method of angulation measurement had higher interrater reproducibility than the posterior tangent method. The interrater reliability for C2-C3 translation using plain films was higher than for measurements made using CT images., Conclusion: Despite widespread acceptance of their importance, radiographic measurements for C2 fractures have, at best, only moderate reliability. Even in the ideal situation created in this study, there is limited agreement. Further work to substantiate the importance and improve the reliability of these measurement parameters is needed.

Background: Despite an increased risk of cervical spine fractures in older patients, little is known about the mortality associated with these fractures and there is no consensus on the optimal treatment. The purposes of this study were to determine the three-month and one-year mortality associated with cervical spine fractures in patients sixty-five years of age or older and to evaluate potential factors that may influence mortality., Methods: We performed a retrospective review of all cervical spine fractures in patients sixty-five years of age or older from 1991 to 2006 at two institutions. Information regarding age, sex, race, treatment type, neurological involvement, injury mechanism, comorbidity, and mortality were collected. Overall risk of mortality and mortality stratified by the above factors were calculated at three months and one year. Cox proportional-hazard regression was performed to identify independent correlates of mortality., Results: Six hundred and forty patients were included in our analysis. The mean age was eighty years (range, sixty-five to 101 years). Two hundred and ninety-four patients (46%) were male, and 116 (18%) were nonwhite. The risk of mortality was 19% at three months and 28% at one year. The effect of treatment on mortality varied with age at three months (p for interaction = 0.03) but not at one year (p for interaction = 0.08), with operative treatment being associated with less mortality for those between the ages of sixty-five and seventy-four years. A higher Charlson comorbidity score, male sex, and neurological involvement were all associated with increased risk of mortality., Conclusions: Operative treatment of cervical spine fractures is associated with a lower mortality rate at three months but not at one year postoperatively for patients between sixty-five and seventy-four years old at the time of fracture.

This commentary is a product of the North American Spine Society (NASS). It was approved by the NASS Board of Directors and accepted for publication outside The Spine Journal's peer review process., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background Context: An ideal classification system for thoracolumbar (TL) spine fractures should facilitate communication between treating physicians and guide treatment by means of outlining the natural history of injuries. The classification scheme should also be comprehensive, intuitive, and simple to implement. At the present time, no classification system fully meets these criteria. In this review, the authors attempt to describe the evolution of TL fracture classification systems from their inception to the present day., Purpose: To review the evolution of TL injury classification schemes, particularly in regard to the progression of thought on the importance of biomechanical stability, injury mechanism, and neurologic status., Study Design: Review article., Methods: The article reviews the salient classification systems that have addressed TL injuries since Boehler's first attempt in 1929. This progression culminates in the Thoracolumbar Injury Severity Score/Thoracolumbar Injury Classification and Severity Score (TLISS/TLICS), a system which incorporates features from earlier scales and represents the most comprehensive grading scale to date., Results: Each successive system played an important role in advancing contemporary understanding of TL injuries. Most classifications were, however, based on a single individual's, or a comparatively small group's, retrospective review of a case series. In most instances, these grading systems were never validated or modified by their original developers, a shortcoming that prevented their continued evolution. Despite the many advantages of the TLISS/TLICS system, more work in terms of refining the classification and defining its validity remains to be performed., Conclusions: The classification of TL injuries has evolved significantly over the course of the last 75 years. Most of these schemes were limited by their complexity, relevance, and/or poor reliability. The TLISS classification system represents the most recent evolution as it combines several important factors capable of guiding the management of TL injuries. Nonetheless, more research regarding this rating scale remains to be performed.

The halo fixator may be used for the definitive treatment of cervical spine trauma, preoperative reduction in the patient with spinal deformity, and adjunctive postoperative stabilization following cervical spine surgery. Halo fixation decreases cervical motion by 30% to 96%. Absolute contraindications include cranial fracture, infection, and severe soft-tissue injury at the proposed pin sites. Relative contraindications include severe chest trauma, obesity, advanced age, and a barrel-shaped chest. In children, a computed tomography scan of the head should be obtained before pin placement to determine cranial bone thickness. Complications of halo fixation include pin loosening, pin site infection, and skin breakdown. A concerning rate of life-threatening complications, such as respiratory distress, has been reported in elderly patients. Despite a paucity of contemporary data, recent retrospective studies have demonstrated acceptable results for halo fixation in managing some upper and lower cervical spine injuries.

Object: Thoracolumbar fractures, treated operatively or nonoperatively, may cause painful kyphotic deformities over time. A pedicle subtraction osteotomy (PSO) is a single-stage posterior procedure designed to correct sagittal plane deformity. Although it was initially used to treat nontraumatic conditions, a PSO can be highly effective in chronic, posttraumatic fractures of the lumbar spine. In this report the authors review details obtained in the treatment of three patients with severe, posttraumatic spinal deformities. They describe the surgical technique used to correct the sagittal malalignments., Methods: All three patients were middle aged, and good bone mineral density had been demonstrated in each case preoperatively. After PSO, a mean 51 degrees improvement in sagittal alignment was achieved and maintained until a solid arthrodesis was documented in each case. Substantial improvements in pain relief and functional outcome were observed. A detailed, procedure-specific literature review was undertaken., Conclusions: A PSO is a valuable tool to add to the armamentarium of neurosurgeons who treat patients suffering from painful posttraumatic deformity following fractures of the upper lumbar spine.

Most thoracolumbar and lumbar burst fractures can be treated conservatively. Unstable fractures or fractures resulting in neurologic deficits usually require surgical treatment. Choosing an appropriate surgical approach requires a thorough understanding of the various techniques for decompression, fusion, and stabilization. Surgical options include an anterior approach, a posterior approach, or a combined anteroposterior approach. Each surgical option has unique advantages and disadvantages. Generally, the anterior approaches are best used at the thoracolumbar junction, posterior approaches are ideal for low lumbar injuries and lumbar injuries that result in complete spinal cord injuries,and anteroposterior surgeries typically are reserved for highly unstable fracture subluxations. Case illustrations show the various treatment options.

Study Design: Retrospective chart review., Objectives: To determine the frequency of stable and unstable cervical spine fractures after gunshot wounds to the head or neck; to identify potential risk factor(s) for an unstable versus stable cervical spine fracture., Summary of Background Data: Cervical spine fractures after gunshot wounds to the head and neck are common. Because of the nature of their injuries, patients often present with concomitant airway obstruction and large blood vessel injury that can necessitate emergent procedures. In some cases, acute treatment of these problems can be hindered by the presence of a cervical collar or strict adherence to spinal precautions (i.e., patient laying supine). In such situations, information regarding the probability of a stable versus unstable cervical spine fracture would be useful in emergency treatment decision making., Methods: A search for patients with gunshot wounds to the head or neck potentially involving the cervical spine over a 13-year period was performed using a trauma registry. Individuals with cervical spine fractures were identified and their records reviewed in detail. Data collected included information about neurologic deficits, mental status, airway treatment, entrance wounds, fracture level/type, initial/definitive fracture treatment, and final disposition at hospital discharge., Results: A total of 81 patients were identified; 19 had cervical spine fractures. There were 5 patients who were not examinable because of altered mental status (severe head trauma, hemorrhagic shock, or intoxication). All 5 patients had stable cervical spine fractures. There were 11 patients who had an acute spinal cord injury, 3 (30%) of whom underwent surgery for an unstable fracture. Of the 65 awake, alert patients without a neurologic deficit, only 3 (5%) had a fracture, none of which were unstable., Conclusions: Gunshot wounds to the head and neck had a high rate of concomitant cervical spine fracture. Neurologically intact patients have a lower rate of fracture than those presenting with a spinal cord injury or altered mental status. In this small series of patients, the only unstable cervical spine injuries were detected in patients with a spinal cord injury. The data suggest that spinal precautions and/or a hard cervical collar should not be maintained at the expense of delaying or hindering emergent life-saving airway or hemodynamically stabilizing procedures, particularly in awake, neurologically intact patients. However, the cervical collar and spinal precautions should be resumed after such procedures are completed and continued until a more definitive evaluation of spinal stability can be performed.

Background Context: The incidence of violent crimes has risen over the past decade. With it, gunshot injuries have become increasingly more common in the civilian population. Among the most devastating injuries are gunshot wounds to the spine., Purpose: The purpose of this article is to provide a thorough review of the pathomechanics, diagnosis and treatment of gunshot wounds to the spine., Study Design/setting: Literature review article., Conclusions: Treatment of gunshot spine fractures differs from other mechanisms. Fractures are usually inherently stable and rarely require stabilization. In neurologically intact patients, there are few indications for surgery. Evidence of acute lead intoxication, an intracanal copper bullet or new onset neurologic deficit can justify operative decompression and/or bullet removal. Overzealous laminectomy can destabilize the spine and lead to late postoperative deformity. For complete and incomplete neural deficits at the cervical and thoracic levels, operative decompression is of little benefit and can lead to higher complication rates than nonsurgically managed patients. With gunshots to the T12 to L5 levels, better motor recovery has been reported after intracanal bullet removal versus nonoperative treatment. The use of steroids for gunshot paralysis has not improved the neurologic outcome and has resulted in a greater frequency of nonspinal complications. Although numerous recommendations exist, 7 to 14 days of broad-spectrum antibiosis has lead to the lowest rates of infection after transcolonic gunshots to the spine.