Sacral Fractures and Associated Injuries.

STUDY DESIGN: Literature review. OBJECTIVE: The aim of this review is to describe the injuries associated with sacral fractures and to analyze their impact on patient outcome. METHODS: A comprehensive narrative review of the literature was performed to identify the injuries associated with sacral fractures. RESULTS: Sacral fractures are uncommon injuries that result from high-energy trauma, and that, due to their rarity, are frequently underdiagnosed and mistreated. Only 5% of sacral fractures occur in isolation. Injuries most often associated with sacral fractures include neurologic injuries (present in up to 50% of sacral fractures), pelvic ring disruptions, hip and lumbar spine fractures, active pelvic/ abdominal bleeding and the presence of an open fracture or significant soft tissue injury. Diagnosis of pelvic ring fractures and fractures extending to the lumbar spine are key factors for the appropriate management of sacral fractures. Importantly, associated systemic (cranial, thoracic, and abdominopelvic) or musculoskeletal injuries should be promptly assessed and addressed. These associated injuries often dictate the management and eventual outcome of sacral fractures and, therefore, any treatment algorithm should take them into consideration. CONCLUSIONS: Sacral fractures are complex in nature and often associated with other often-missed injuries. This review summarizes the most relevant associated injuries in sacral fractures and discusses on their appropriate management

The Development of a Universally Accepted Sacral Fracture Classification: A Survey of AOSpine and AOTrauma Members.

Study Design Survey study. Objective To determine the global perspective on controversial aspects of sacral fracture classifications. Methods While developing the AOSpine Sacral Injury Classification System, a survey was sent to all members of AOSpine and AOTrauma. The survey asked four yes-or-no questions to help determine the best way to handle controversial aspects of sacral fractures in future classifications. Chi-square tests were initially used to compare surgeons\u27 answers to the four key questions of the survey, and then the data was modeled through multivariable logistic regression analysis. Results A total of 474 surgeons answered all questions in the survey. Overall 86.9% of respondents felt that the proposed hierarchical nature of injuries was appropriate, and 77.8% of respondents agreed that that the risk of neurologic injury is highest in a vertical fracture through the foramen. Almost 80% of respondents felt that the separation of injuries based on the integrity of L5-S1 facet was appropriate, and 83.8% of surgeons agreed that a nondisplaced sacral U fracture is a clinically relevant entity. Conclusion This study determines the global perspective on controversial areas in the injury patterns of sacral fractures and demonstrates that the development of a comprehensive and universally accepted sacral classification is possible

Early Experience With Uniplanar Versus Biplanar Expandable Interbody Fusion Devices in Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion

ObjectiveTo compare the early radiographic and clinical outcomes of expandable uniplanar versus biplanar interbody cages used for single-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). MethodA retrospective review of 1-level MIS-TLIFs performed with uniplanar and biplanar polyetheretherketone cages was performed. Radiographic measurements were performed on radiographs taken preoperatively, at 6-week follow-up, and 1-year follow-up. Oswestry Disability Index (ODI) and visual analogue scale (VAS) for back and leg at 3-month and 1-year follow-up. ResultsA total of 93 patients (41 uniplanar, 52 biplanar) were included. Both cage types provided significant postoperative improvements in anterior disc height, posterior disc height, and segmental lordosis at 1 year. No significant differences in cage subsidence rates were found between uniplanar (21.9%) and biplanar devices (32.7%) at 6 weeks (odds ratio, 2.015; 95% confidence interval, 0.651–6.235; p = 0.249) with no additional instances of subsidence at 1 year. No significant differences in the magnitude of improvements based on ODI, VAS back, or VAS leg at 3-month or 1-year follow-up between groups and the proportion of patients achieving the minimal clinically important difference in ODI, VAS back, or VAS leg at 1 year were not statistically significantly different (p \u3e 0.05). Finally, there were no significant differences in complication rates (p = 0.283), 90-day readmission rates (p = 1.00), revision surgical procedures (p = 0.423), or fusion rates at 1 year (p = 0.457) between groups. ConclusionsBiplanar and uniplanar expandable cages offer a safe and effective means of improving anterior disc height, posterior disc height, segmental lordosis, and patient-reported outcome measures at 1 year postoperatively. No significant differences in radiographic outcomes, subsidence rates, mean subsidence distance, 1-year patient-reported outcomes, and postoperative complications were noted between groups

Is facet joint distraction a cause of postoperative axial neck pain after ACDF surgery?

Introduction: Intervertebral distraction in anterior cervical discectomy and fusion (ACDF) has been postulated to injure the degenerative facet joints posteriorly and increase postoperative pain and disability. This study aims to determine if there is a correlation between the amount of facet distraction and postoperative patient reported outcomes. Methods: A retrospective cohort analysis of patients undergoing ACDF for degenerative pathologies was performed. Each patient received lateral cervical spine x-rays at the immediate postoperative time point and were split into groups based on the amount of facet distraction measured on these films: Group A: \u3c 1.5 mm; Group B: 1.5-2.0 mm; and Group C: \u3e 2.0 mm. Patients reported outcome measures were obtained preoperatively and at 1-year postoperatively. Univariate and multivariate analyses were performed to compare outcomes between groups. Results: A total of 229 patients were included with an average follow-up of 19.8 [19.0, 20.7] months with a mean facet joint distraction of 1.7mm. There were 87 patients in Group A, 76 patients in Group B, and 66 patients in Group C. Patients significantly improved across all outcome measures from baseline to postoperatively (p \u3c 0.05). There was no difference between groups at any time point with respect to outcome scores (p \u3e 0.05). Multiple regression analysis did not identify increasing distraction as a predictor of patient outcomes. Conclusions: There were no significant differences between patient outcomes and the amount of facet distraction after ACDF surgery. Multivariate analysis did not find a correlation between facet distraction and overall HRQOL outcome

Perioperative Chanage in Cervical Lordosis and Health-Related Quality-of-Life Outcomes

BACKGROUND: Surgeons have scrutinized spinal alignment and its impact on improving clinical outcomes following anterior cervical discectomy and fusion (ACDF). The primary analysis of this study examines the relationship between change in perioperative cervical lordosis (CL) and health-related quality-of-life (HRQOL) outcomes after ACDF. Secondary analysis evaluates the effects of fusion construct length on outcomes in patients grouped by preoperative cervical alignment. METHODS: A retrospective cohort study was performed on an institutional database including patients who underwent 1- to 3-level ACDF. C2-C7 CL was measured preoperatively and at final follow-up. For primary analysis, patients were classified based on their perioperative cervical lordotic correction: (1) kyphotic, (2) maintained, and (3) restored. For secondary analysis, patients were categorized based on their preoperative C2-C7 CL: (1) kyphotic, (2) neutral, and (3) lordotic. Demographics and perioperative change in patient-reported outcome measures were compared between groups. RESULTS: A total of 308 patients were included. A significant difference was noted among maintained, restored, and kyphotic groups in terms of delta physical compositeshort form-12 score (ΔPCS-12) (9.0 vs 10.3 vs 1.5; CONCLUSIONS: Significantly greater PCS-12 and VAS arm improvement were seen in patients whose cervical sagittal alignment was restored to neutral/lordotic compared with those who remained kyphotic. Multivariate analysis demonstrated no association between construct length and perioperative outcomes. CLINICAL RELEVANCE: The results of this study highlight the importance of sagittal alignment and restoration of CL after short-segment ACDF. Irrespective of preoperative sagittal alignment, the length of ACDF fusion construct does not have a significant impact on clinical outcomes

Does Smoking Status Influence Health-Related Quality of Life Outcome Measures in Patients Undergoing ACDF?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: Whereas smoking has been shown to affect the fusion rates for patients undergoing an anterior cervical discectomy and fusion (ACDF), the relationship between smoking and health-related quality of life outcome measurements after an ACDF is less clear. The purpose of this study was to evaluate whether smoking negatively affects patient outcomes after an ACDF for cervical degenerative pathology. METHODS: Patients with tumor, trauma, infection, and previous cervical spine surgery and those with less than a year of follow-up were excluded. Smoking status was assessed by self-reported smoking history. Patient outcomes, including Neck Disability Index, Short Form 12 Mental Component Score, Short Form 12 Physical Component Score (PCS-12), Visual Analogue Scale (VAS) arm pain, VAS neck pain, and pseudarthrosis rates were evaluated. Outcomes were compared between smoking groups using multiple linear and logistic regression, controlling for age, sex, and body mass index (BMI), among other factors. A P value \u3c.05 was considered significant. RESULTS: A total of 264 patients were included, with a mean follow-up of 19.8 months, age of 53.1 years, and BMI of 29.6 kg/m2. There were 43 current, 69 former, and 152 nonsmokers in the cohort. At baseline, nonsmokers had higher PCS-12 scores than current smokers (P = .010), lower VAS neck pain than current (P = .035) and former (P = .014) smokers, as well as lower VAS arm pain than former smokers (P = .006). Postoperatively, nonsmokers had higher PCS-12 scores than both current (P = .030) and former smokers (P = .035). Smoking status was not a significant predictor of change in patient outcome in multivariate analysis. CONCLUSIONS: Whereas nonsmokers had higher function and lower pain than former or current smokers preoperatively, smoking status overall was not found to be an independent predictor of outcome scores after ACDF. This supports the notion that smoking status alone should not deter patients from undergoing ACDF for cervical degenerative pathology

How Does Spinopelvic Alignment Influence Short-Term Clinical Outcomes After Lumbar Fusion in Patients With Single-Level Degenerative Spondylolisthesis?

Context: Studies on adult spinal deformity have shown spinopelvic malalignment results in worse outcomes. However, it is unclear if this relationship exists in patients with single‑level degenerative spondylolisthesis (DS) receiving short‑segment fusions. Aims: To determine if spinopelvic alignment affects patient‑reported outcome measures (PROMs) after posterior lumbar decompression and fusion (PLDF) with or without a transforaminal lumbar interbody fusion in patients with L4‑5 DS. Settings and Design: A retrospective cohort analysis was conducted on patients who underwent PLDF for L4‑5 DS at a single tertiary referral academic medical center. Materials and Methods: Patients were divided into groups based on preoperative cutoff values of 20° for pelvic tilt (PT) and 11° for pelvic incidence‑lumbar lordosis mismatch (PI‑LL) with subsequent reclassification based on correction to \u3c20° PT or 11° PI‑LL. Radiographic outcomes and PROMs were compared between the groups. Statistical Analysis Used: Multiple linear regression analyses were performed to determine whether radiographic cutoff values served as the independent predictors of change in PROMs. Statistical significance was set at P \u3c 0.05. Results: A total of 188 patients with completed PROMs were included for the analysis.Preoperative PT \u3e20° was associated with significantly greater reduction in PI‑LL (−2.41° vs. 1.21°, P = 0.004) and increase in sacral slope (SS) (1.06° vs. −1.86°, P = 0.005) compared to patients with preoperative PT \u3c20°. On univariate analysis, no significant differences were observed between any groups with regard to PROMs. Preoperative sagittal alignment measures and postoperative correction were not found to be independent predictors of improvement in clinical outcomes. Conclusion: A preoperative PT \u3e20° is associated with improved PI‑LL reduction and an increase in SS. However, no differences in clinical outcomes were found 1 year postoperatively for patients with preoperative PT \u3e20° and PI‑LL ≥11° compared to patients below this threshold