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Letter to the Editor: Axis fractures

Andrei F. Joaquim

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Letter to the Editor: Treatment of craniocervical instability using a posterior-only approach

Andrei F. Joaquim

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Letter to the Editor: Thoracolumbar Injury Classification and Severity Score

Yongjun Tong and Quanzhou Wu

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Letter to the Editor: Thoracolumbar Injury Classification and Severity Score

Yongjun Tong and Quanzhou Wu

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Letters to the editor: Validating the Thoracolumbar Injury Classification and Severity Score

Zachary A. Smith and Nader S. Dahdaleh

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Letters to the editor: Burst fractures

Andrei F. Joaquim and Alpesh A. Patel

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Clinical results of patients with thoracolumbar spine trauma treated according to the Thoracolumbar Injury Classification and Severity Score

Clinical article

Andrei F. Joaquim, Enrico Ghizoni, Helder Tedeschi, Ulysses Caus Batista, and Alpesh A. Patel

Object

The Thoracolumbar Injury Classification and Severity Score (TLICS) was developed to improve injury classification and guide surgical decision making, yet validation remains necessary. This study evaluates the neurological outcome of patients with thoracolumbar spine trauma (TLST) treated according to the TLICS.

Methods

The TLICS was prospectively applied to a consecutive series of patients treated for TLST between 2009 and 2012. Patients with a TLICS of 4 points or more were surgically treated, whereas patients with a TLICS of 3 points or fewer were conservatively managed. The primary outcome was the American Spinal Injury Association Impairment Scale (AIS).

Results

A total of 65 patients were treated. In 37 patients, the TLICS was 3 points or fewer and the patients were treated nonsurgically (Group 1). The remaining 28 patients with a TLICS of 4 or more points underwent surgical treatment (Group 2). In Group 1, 28 patients underwent some follow-up at the authors' institution; all of these patients were neurologically intact with compression or burst fractures (TLICS of 1 or 2 points; median 2). The average age in this group was 44.5 years, and follow-up ranged from 1 to 36 months (mean 6.7 months, median 3 months). Two patients (both with a TLICS of 2 points) underwent late surgery for axial back pain and mild focal kyphosis, without significant clinical improvement. In Group 2, follow-up ranged from 1 to 18 months (mean 4.4 months, median 3 months) and the TLICS ranged from 4 to 10 points (median 7 points). In this group, preoperatively, 9 (32%) patients had AIS Grade E injuries, 6 (21%) had AIS Grade C, 1 (4%) had AIS Grade B, and 12 (43%) had AIS Grade A injuries. At the final follow-up, the AIS grade was E in 11 patients (39%), D in 5 (18%), and A in 12 (43%). No patient had neurological worsening during the follow-up.

Conclusions

The TLICS can be used to guide treatment that is safe with regard to the neurological status of patients treated for TLST.

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Man-in-the-barrel syndrome after thoracoilium fusion

Case Report

Andrei F. Joaquim, Catherine C. Shaffrey, Charles A. Sansur, and Christopher I. Shaffrey

The authors report a case of man-in-the-barrel (MIB) syndrome occurring after an extensive revision involving thoracoilium instrumentation and fusion for iatrogenic and degenerative scoliosis, progressive kyphosis, and sagittal imbalance. Isolated brachial diplegia is a rare neurological finding often attributed to cerebral ischemia. It has not been previously reported in patients undergoing complex spine surgery. This 70-year-old woman, who had previously undergone T11–S1 fusion for lumbar stenosis and scoliosis, presented with increased difficulty walking and with back pain. She had junctional kyphosis and L5–S1 pseudarthrosis and required revision fusion extending from T-3 to the ilium. In the early postoperative period, she experienced a 30-minute episode of substantial hypotension. She developed delirium and isolated brachial diplegia, consistent with MIB syndrome. Multiple studies were performed to assess the origin of this brachial diplegia. There was no definitive radiological evidence of any causative lesion. After a few days, her cognitive function returned to normal and she regained the ability to move her arms. After several weeks of rehabilitation, she recovered completely. Man-in-the-barrel syndrome is a rare neurological entity. It can result from various mechanisms but most commonly seems to be related to ischemia and is potentially reversible.

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Pseudarthrosis in anterior cervical discectomy and fusion with a self-locking, stand-alone cage filled with hydroxyapatite: a retrospective study with clinical and radiological outcomes of 98 levels with a minimum 2-year follow-up

Eduardo A. Iunes, Enrico A. Barletta, Telmo A. B. Belsuzarri, Franz J. Onishi, André Y. Aihara, Sergio Cavalheiro, and Andrei F. Joaquim

OBJECTIVE

The goal of this study was to evaluate the incidence of pseudarthrosis after the treatment of cervical degenerative disc disease (CDDD) with anterior cervical discectomy and fusion (ACDF) in which self-locking, stand-alone intervertebral cages filled with hydroxyapatite were used.

METHODS

The authors performed a retrospective cohort study of 49 patients who underwent 1- to 3-level ACDF with self-locking, stand-alone intervertebral cages without plates, with a minimum 2 years of follow-up. The following data were extracted from radiological and clinical charts: age, sex, time and type of pre- and postoperative signs and symptoms, pain status (visual analog scale [VAS]), functional status (Neck Disability Index [NDI]), history of smoking, bone quality (bone densitometry), and complications. Pseudarthrosis was diagnosed by a blinded neuroradiologist using CT scans. Clinical improvement was assessed using pre- and postoperative comparison of VAS and NDI scores. The Wilcoxon test for paired tests was used to evaluate statistical significance using a p value of < 0.05.

RESULTS

Three patients (6%) developed symptomatic pseudarthrosis requiring reoperation, with only 1 patient showing clinical worsening due to pseudarthrosis, while the other 2 with pseudarthrosis had associated disc disease at an adjacent level. The rate of symptomatic pseudarthrosis according to the number of operated levels was 0% for 1 level, 8.7% (2/23 patients) for 2 levels, and 7.7% (1/13 patients) for 3 levels. The total pseudarthrosis rate (including both symptomatic and asymptomatic patients) was 16.4%. Considering the clinical outcomes, there was a significant improvement of 75.6% in neck pain and 95.7% in arm pain, as well as a 64.9% improvement in NDI scores. Complications were observed in 18.4% of patients, with adjacent-level degenerative disease being the most prevalent at 14.3%.

CONCLUSIONS

ACDF with self-locking, stand-alone cages filled with a hydroxyapatite graft can be used for the surgical treatment of 1- to 3-level CDDD with clinical and radiological outcomes significantly improved after a minimum 2-year follow-up period. Comparative studies are necessary.

Open access

Effect of surgical experience and spine subspecialty on the reliability of the AO Spine Upper Cervical Injury Classification System

Mark J. Lambrechts, Gregory D. Schroeder, Brian A. Karamian, Jose A. Canseco, F. Cumhur Oner, Lorin M. Benneker, Richard J. Bransford, Frank Kandziora, Shanmuganathan Rajasekaran, Mohammad El-Sharkawi, Rishi Kanna, Andrei Fernandes Joaquim, Klaus Schnake, Christopher K. Kepler, Alexander R. Vaccaro, and the AO Spine Upper Cervical Injury Classification International Members

OBJECTIVE

The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (< 5 years, 5–10 years, 10–20 years, and > 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery).

METHODS

A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson’s chi-square or Fisher’s exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility.

RESULTS

The intraobserver reproducibility was substantial for surgeon experience level (< 5 years: 0.74 vs 5–10 years: 0.69 vs 10–20 years: 0.69 vs > 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (< 5 years: 0.67 vs 5–10 years: 0.62 vs 10–20 years: 0.61 vs > 20 years: 0.62), and only surgeons with > 20 years of experience did not have substantial reliability on assessment 2 (< 5 years: 0.62 vs 5–10 years: 0.61 vs 10–20 years: 0.61 vs > 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36).

CONCLUSIONS

The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system.