Ingrid Radovanovic, Jennifer C. Urquhart, Parham Rasoulinejad, Kevin R. Gurr, Fawaz Siddiqi and Christopher S. Bailey
Previous studies have focused on Type II odontoid fractures and have failed to report on the effect of other C-2 fracture types on treatment and outcome. The purpose of this study was to compare patient characteristics, cause of injury, predisposing factors to fracture, treatments, and mortality rates among C-2 fracture types in a cohort of elderly patients 70 years of age and older.
A retrospective cohort study design was used. Patients who sustained a C-2 fracture between 2002 and 2011 and who were admitted to the authors’ Level 1 trauma center were identified using the Discharge Abstract Database and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code S12.1. Fractures were classified as odontoid Type I, II, or III; hangman’s; C-2 complex (hangman’s appearance on sagittal images, Type III odontoid on coronal cuts); and other (miscellaneous). Age, sex, predisposing factors to falls, cause of injury, treatment, presence of autofusion in the subaxial cervical spine, and mortality rates were compared between fracture patterns.
One hundred forty-one patients were included; their mean age was 82 years. Fractures included Type II odontoid (57%), complex (19%), Type III odontoid (11%), hangman’s (8%), and other (5%). Falls from a standing height accounted for 47% of injuries, and 65% of patients had ≥ 3 risk factors for falls. Subaxial autofusion was more common in odontoid fractures (p = 0.002). Treatment was mainly nonoperative (p < 0.0001). The 1-year mortality rate was 27%. Four patients died of spinal cord injury.
Although not as common as Type II odontoid fractures, other C-2 fractures including hangman’s, complex, and Type III odontoid fractures accounted for close to half of the injuries in the study cohort. There were few differences between the fracture types with respect to cause of injury, predisposing factors, or mortality rate. However, surgical treatment was more common for Type II odontoid fractures.
Jennifer C. Urquhart, Osama A. Alrehaili, Charles G. Fisher, Alyssa Fleming, Parham Rasoulinejad, Kevin Gurr, Stewart I. Bailey, Fawaz Siddiqi and Christopher S. Bailey
A multicenter, prospective, randomized equivalence trial comparing a thoracolumbosacral orthosis (TLSO) to no orthosis (NO) in the treatment of acute AO Type A3 thoracolumbar burst fractures was recently conducted and demonstrated that the two treatments following an otherwise similar management protocol are equivalent at 3 months postinjury. The purpose of the present study was to determine whether there was a difference in long-term clinical and radiographic outcomes between the patients treated with and those treated without a TLSO. Here, the authors present the 5- to 10-year outcomes (mean follow-up 7.9 ± 1.1 years) of the patients at a single site from the original multicenter trial.
Between July 2002 and January 2009, a total of 96 subjects were enrolled in the primary trial and randomized to two groups: TLSO or NO. Subjects were enrolled if they had an AO Type A3 burst fracture between T-10 and L-3 within the previous 72 hours, kyphotic deformity < 35°, no neurological deficit, and an age of 16–60 years old. The present study represents a subset of those patients: 16 in the TLSO group and 20 in the NO group. The primary outcome measure was the Roland Morris Disability Questionnaire (RMDQ) score at the last 5- to 10-year follow-up. Secondary outcome measures included kyphosis, satisfaction, the Numeric Rating Scale for back pain, and the 12-Item Short-Form Health Survey (SF-12) Mental and Physical Component Summary (MCS and PCS) scores. In the original study, outcome measures were administered at admission and 2 and 6 weeks, 3 and 6 months, and 1 and 2 years after injury; in the present extended follow-up study, the outcome measures were administered 5–10 years postinjury. Treatment comparison between patients in the TLSO group and those in the NO group was performed at the latest available follow-up, and the time-weighted average treatment effect was determined using a mixed-effects model of longitudinal regression for repeated measures averaged over all time periods. Missing data were assumed to be missing at random and were replaced with a set of plausible values derived using a multiple imputation procedure.
The RMDQ score at 5–10 years postinjury was 3.6 ± 0.9 (mean ± SE) for the TLSO group and 4.8 ± 1.5 for the NO group (p = 0.486, 95% CI −2.3 to 4.8). Average kyphosis was 18.3° ± 2.2° for the TLSO group and 18.6° ± 3.8° for the NO group (p = 0.934, 95% CI −7.8 to 8.5). No differences were found between the NO and TLSO groups with time-weighted average treatment effects for RMDQ 1.9 (95% CI −1.5 to 5.2), for PCS −2.5 (95% CI −7.9 to 3.0), for MCS −1.2 (95% CI −6.7 to 4.2) and for average pain 0.9 (95% CI −0.5 to 2.2).
Compared with patients treated with a TLSO, patients treated using early mobilization without orthosis maintain similar pain relief and improvement in function for 5–10 years.
Bailey A. Dyck, Christopher S. Bailey, Chris Steyn, Julia Petrakis, Jennifer C. Urquhart, Ruheksh Raj and Parham Rasoulinejad
This proof-of-concept study was conducted to determine whether negative-pressure wound therapy, through the use of incisional vacuum-assisted closure (VAC), is associated with a reduction in surgical site infections (SSIs) when compared to standard wound dressings in patients undergoing open posterior spinal fusion who have a high risk of infection.
A total of 64 patients were examined; 21 patients received incisional VAC application (VAC group) versus 43 diagnosis-matched patients who received standard wound dressings (control group). Patients in the VAC group were prospectively enrolled in a consecutive series between March 2013 and March 2014 if they met the following diagnostic criteria for high risk of infection: posterior open surgery across the cervicothoracic junction; thoracic kyphosis due to metastatic disease; high-energy trauma; or multilevel revision reconstructive surgery. Patients in the VAC group also met one or more comorbidity criteria, including body mass index ≥ 35 or < 18.5, diabetes, previous radiation at surgical site, chemotherapy, steroid use, bedridden state, large traumatic soft-tissue disruption, or immunocompromised state. Consecutive patients in the control group were retrospectively selected from the previous year by the same high-risk infection diagnostic criteria as the VAC group. All surgeries were conducted by the same surgeon at a single site. The primary outcome was SSI. All patients had 1 year of follow-up after their surgery. Baseline demographics, intraoperative parameters, and postoperative wound infection rates were compared between groups.
Patient demographics including underlying comorbidities were similar, with the exception that VAC-treated patients were malnourished (p = 0.020). VAC-treated patients underwent longer surgeries (p < 0.001) and required more postoperative ICU admissions (p = 0.039). The median length of hospital stay was not different between groups. In total, 9 control patients (21%) developed an SSI, versus 2 VAC-treated patients (10%).
Patients in this cohort were selected to have an increased risk of infection; accordingly, the rate of SSI was high. However, negative-pressure wound therapy through VAC application to the postoperative incision resulted in a 50% reduction in SSI. No adverse effects were noted secondary to VAC application. The preliminary data confirm the authors’ proof of concept and strongly support the need for a prospective randomized trial.