The purpose was to present a case of cauda equina entrapment in a lumbar burst fracture with associated lamina fracture and to review the literature and assess the appropriateness of current practices for cauda equina decompression. Reported incidence of cauda equina entrapment in the lamina fracture of lumbar burst fractures is 13–17%. Anterior surgery alone for decompressing the cauda equina in patients with lumbar burst fractures and associated lamina fractures will not always address the problem. We therefore suggest that posterior exploration may be the preferred approach if the aim of surgery is to decompress the neural elements

Summary Statement. Using abdominal CT scans to evaluate bone mineral density following acute fractures of the thoracic and lumbar spine demonstrates significant levels of osteoporosis in older patients; this approach may help save on time and resources, and reduce unnecessary radiation exposure. Introduction. While a reduction in bone mineral density (BMD) is associated with aging, relatively few patients have formal dual-energy X-ray absorptiometry (DXA) to quantify the magnitude of bone loss, as they age. This loss of bone may predispose to fractures. Recent data, which correlates mean Hounsfield units (HU) in an area of the L1 vertebra with BMD, now makes it possible to screen for osteoporosis using incidental abdominal Computed Tomography (CT) scans to measure bone density. This innovation has the potential to reduce both cost and radiation exposure, and also make it easier to identify patients who may be at risk. The aims of this study were to evaluate the utility of this approach in patients with acute thoracic and lumbar spine fractures and to evaluate the impact of aging on BMD, using CT screening. Patients & Methods. Following institutional review board approval, we performed a retrospective study of patients who presented to a level I trauma center with acute fractures of the thoracic and lumbar spine between 2010 and 2013; patients also had to have had an abdominal (or L1) CT scan either during the admission or in the 6 months before or after their injury. Using a picture archiving and communication (PACS) system, we generated regions of interest (ROI) of similar size in the body of L1 (excluding the cortex) and computed mean values for HU. Values derived were compared against threshold values which differentiate between osteoporosis and osteopenia - for specificity of 90%, a threshold of 110 was set; for balanced sensitivity and specificity, a threshold of <135 HU was set and for 90% sensitivity a threshold of <160 HU was set. A student's t test was used to compare the age stratified mean HU (younger than 65yrs; 65yrs and older), while Fisher's exact test was used to perform aged stratified comparisons between the proportions of patients above and below the thresholds outlined (in each of the three threshold groups). Results. A total of 124 patients were evaluated, with 74 having thoracic and 50 having lumbar fractures. Among those with thoracic fractures, there were 33patients in the younger cohort, who also had a mean BMD of 196.51HU and 41 in the older cohort, who had mean BMD of 105.90HU (p<0.001). In patients with lumbar fractures, 27 patients were in the younger cohort, with mean BMD of 192.26HU and 23 patients in the older cohort with mean BMD of 114.31HU (p<0.001). At the threshold of 110 HU, set for specificity, the magnitude of difference between the age stratified cohorts was greater in the thoracic spine (p<0.001 vs. p=0.003). At the other thresholds: 135HU (balanced for sensitivity and specificity) and 160 HU (90% sensitivity), age of 65 years or older was significantly associated with reduction in CT derived measure of BMD (p<0.001 in all cases). Discussion. This study demonstrates the relative frequency of osteoporosis in acute fractures of the thoracic and lumbar spine, and how this changes with age; it is also the first study to do this using opportunistic CT scans. There seems to be a strong association between a reduction in bone mineral density and advanced age, in patients presenting with acute fractures of the spine. This approach may save on the extra cost and additional radiation exposure that may be associated with DXA scanning; in addition, it may help provide clinicians and patients with an approach to monitor developing problems with BMD before it becomes clinically apparent, especially in younger patients

Objective: To assess the result of surgical stabilisation of spine in Spinal cord injured patients. Design: Retrospective review of patients managed and followed at a spinal injury centre. Subjects: Sixty-six patients with spinal cord injury, treated with surgical stabilisation of their spinal fracture and followed for a minimum of two years. Outcome Measures: Delay in starting ambulation from injury/surgery, sagittal balance, metalwork failure and surgical complications. Results: The mean age was 29.5 years (17–67), and five patients were female. The median follow up was 7.9 years (2–24). There were 19 cervical, 21 thoracic and 28 thoracolumbar and lumbar fractures. A total of 36 patients had over six weeks delay in starting ambulation. Of these 11 were due to inadequate fixation. Ten patients (50%) with cervical fracture and seven patients (25%) with lumbar fractures had normal lordosis. Significantly more patients with anterior cervical fixation had normal lordosis compared to those with posterior fixation. Nineteen with thoracic fracture had thoracic kyphosis within 40°. Nine patients had failure of metalwork. Surgical complications occurred in 21 (33%) patients. Conclusion: Early ambulation was not achieved in the majority. The maintenance of lordosis was successful in cervical but not in lumbar spine. Posterior fixation of thoracic spine was successful in maintaining normal sagittal balance

Purpose: The purpose of this study was to assess the clinical, radiological, and functional outcomes following the treatment of a lumbar Chance fracture and to analyze the spectrum of associated abdominal injuries as seen in the Seat Belt Syndrome. Methods: All patients diagnosed with L1 to L4 Chance fractures were included in this study. Patient data, injuries, treatment and complications were collected from hospital charts. A review of all available spinal radiology was done to measure pre-treatment, post-treatment and follow-up kyphosis angles. We have also described and calculated a Chance Fracture Deformity Index. Patients were seen in follow-up to assess for range of motion, tenderness and neurological status. A functional outcome questionnaire by the AAOS Pediatric Instruments was completed by the patients. Results: Between December 1984 and February 2001, 27 patients aged 3 to 17 were treated for lumbar Chance fractures. The mean age at injury was 11.1 years. There were 17 females and 8 males. All injuries occurred as a result of a motor vehicle accident. Of the 25 patients, 17 were treated surgically. 12 patients had abdominal injuries. 3 cases involved abdominal arterial vascular trauma. Significant improvement in intra-vertebral kyphosis, segmental kyphosis, and vertebral kyphosis redmodelling (6.5 vs. 4 degrees) was noted in the operative group compared to the non-operative group. The disease specific AAOS Lumbar Spine Questionnaire scores were poor for pain and disability, 29.22, (26.41–31.98), but the SF-36 scores for both MCS and PCS were within the normal range, 47.79 (44.03–51.54) and 47.71 (42.59–52.82), respectively. Conclusions: An abdominal and spinal CT must be taken when presented with a Chance fracture with abdominal symptoms. Injury type and kyphosis angle are the main factors that aid in treatment planning in paediatric lumbar chance fractures. A purely soft-tissue injury or a kyphosis angle greater than 20 requires surgical intervention

Introduction and Aims: The aims of this study were to assess the clinical and functional outcomes following the treatment of a lumbar Chance fracture and to analyse the spectrum of associated abdominal injuries as seen in the Seat Belt Syndrome. Method: All patients diagnosed with L1 to L4 Chance fractures at the British Columbia Children’s Hospital were included in this study. Patient data, injuries, treatment and complications were collected from hospital charts. A review of all available spinal radiology including pre-treatment, post-treatment and follow-up x-rays, CTs and MRIs was done to measure pre-treatment, post-treatment and follow-up kyphosis angles, as well as to help classify the Chance fracture. Patients were seen in follow-up to assess for range of motion, tenderness and neurological status. Furthermore, a functional outcome questionnaire by the American Academy of Orthopaedic Surgeons Pediatric Instruments was completed by the patients. Results: Between December 1984 and February 2001, 27 patients aged three to 17 were treated for lumbar Chance fractures. The mean age at injury was 11.1 years. There were 18 females and nine males. All injuries occurred as a result of a motor vehicle accident. Nineteen were rear-seat passengers and eight were front-seat passengers. Of the 27 patients, 19 were treated surgically. Of these 19, nine were treated with either pedicle screws or laminar hooks and rods, four with intersegmental spinous process (ISP) wires alone, two with sublaminar wires and four with a combination of screws/hooks, rods and ISP wires. One patient had a post-operative urinary tract infection. Of the eight patients treated conservatively, four were treated with a hyperextension cast and four were treated with a hyperextension brace. Neurological impairment was seen in seven of the 19 surgical patients pre-operatively. Post-operatively impairment was impoved in two of the seven patients. One of the eight patients treated conservatively had neurological impairment which spontaneously resolved. A total of 13 patients underwent surgery for an associated abdominal injury. Three cases involved abdominal arterial vascular trauma and 12 involved small bowel injury. Conclusion: An abdominal and spinal CT must be taken when presented with a Chance fracture with abdominal symptoms. Injury type and kyphosis angle are the main factors that aid in treatment planning in paediatric lumbar chance fractures. A purely soft-tissue injury or a kyphosis angle greater than 20 requires surgical intervention

The reported results of compression fractures are poor. These results are not influenced by the severity of compression, the fracture site or the residual deformity. Otherwise, the factors that determine a patient's recovery are unknown. This study wants to identify the factors determining a patient's recovery after surgical treatment of compression fractures of the thoracolumbar spine. Therefore, in 31 surgically treated patients the pre-injury versus the 12-month follow-up differences in back pain, in global outcome and in participation were prospectively recorded. For this, the visual analogue scale for pain (VAS scale) and the Greenough and Fraser low back outcome scale were used. Of the latter scale, the 3 questions pertaining to participation were combined to create a participation subscale. For these differences and for time lost from work multiple linear regressions with combinations of 16 possible predictors were performed. At one year patients who smoke report a 25% less favorable global outcome and return 2.8 points (out of 10) less closely to their pre-injury pain level than patients who do not smoke. Patients with a fracture at the thoraco-lumbar junction return 3.3 points less closely to their pre-injury level on the VAS scale than those with a lumbar fracture. For each decrease in 1 of the 3 education levels, the patients stay away from work 15 weeks longer. Per degree of sagittal index at follow-up, patients stay 9 days longer at home. For each increase in level of occupation the return to the pre-injury participation level is 10% less favorable. The variability of time lost from work and of recovery of global outcome, pain and participation level explained by our models is 73%, 37%, 25% and 13% respectively. Smoking, localization of the fracture at the thoraco-lumbar junction and a high pre-existent level of occupation are strong negative predictors for recovery. A lower education level and sagittal fracture deformity at follow-up are negative predictors for sick leave but might also reflect the concerns of the physician when deciding about return to work

Spinal Biomechanics Lab, Baylor College of Medicine, Houston, Texas, USA. Documenting the patterns and frequency of collapse in non-operatively managed spine fractures, using a motion analysis software. Retrospective analysis of prospective case series. 105 patients with thoracic or lumbar fractures, were neurologically intact, and treated non-operatively for the ‘stable’ injury at our unit between June 2003 and May 2006. The mean age of the cohort was 46.9 yrs. Serial radiographs (mean 4 radiographs/patient; range 2 – 9) were analysed using motion analysis software for collapse at the fracture site. We defined collapse as a reduction of anterior or posterior vertebral body height greater than 15% of the endplate AP width, or a change in the angle between the inferior and superior endplates > 5°. The changes were assessed on serial radiographs performed at a mean of 5.6 mo (95% CI 4.1 – 7.1 mo) after the initial injury. 11% showed anterior collapse, 7.6% had posterior collapse, 14% had collapse apparent as vertebral body wedging, and 17% had any form of collapse. ODI scores were obtained in 35 patients at the time of the last available radiograph. There were no significant differences in ODI scores that could be associated with the presence of any form of collapse (p > 0.8 for anterior collapse; and p = 0.18 for posterior collapse). This pilot study with the motion analysis software demonstrates that some fractures are more likely to collapse with time. We hope to carry this work forward by way of a prospective study with a control on other variables that are likely to affect the pattern and probability of post-fracture collapse, including age, bone density, vertebral level, activity level, fracture type

Background. High velocity vertical aircraft ejection seat systems are credited with aircrew survival of 80-95% in modern times. Use of these systems is associated with exposure of the aircrew to vertical acceleration forces in the order of 15-25G. The rate of application of these forces may be up to 250G per sceond. Up to 85% of crew ejecting suffer skeletal injury and vertebral fracture is relatively common (20-30%) when diagnosed by plain radiograph. The incidence of subtle spinal injury may not be as apparent. Aim. A prospective study to evaluate spinal injury following high velocity aircraft ejection. Methods. A prospective case series from 1996 to 2006 was evaluated. During this interval 26 ejectees from 20 aircraft were admitted to the spinal studies unit for comprehensive examination, evaluation and management. The investigations included radiographs of the whole spine and Magnetic Resonance Imaging (incorporating T1, T2 weighted and STIR sagittal sequences). All ejections occurred within the ejection envelope and occurred at an altitude under 2000 feet (mean 460 feet) and at an airspeed less than 500 knots (mean 275 knots). Results. in this series 6 ejectees (24%) had clinical and radiographic evidence of vetebral compression fractures. These injuries were located in the thoracic and thoracolumbar spine. 4 cases required surgery (indicated for angular kyphosis greater than 30 degrees, significant spinal canal compromise, greater than 50% or neurological injury. 1 patient had significant neurological compromise, following an AO A3.3 injury involving the L2 vertebra. 11 ejectees (45 %) had MRI evidence of a combined total of 22 occult thoracic and lumbar fractures. The majority of these ejectees with occult injury had multilevel injuries. Conclusion. This study confirms a high incidence of spinal fracture and particularly occult spinal injury

Objective: To assess the temporal geometric sagittal profile changes on serial radiographs of fractures of the thoracic and thoraco-lumbar spine. Materials and methods: We have included 103 patients with thoracic or lumbar fractures were treated at our unit between June 2003 and May 2006. The patients were suitable for non-operative treatment. The mean age of the cohort was 46.9±2.4 (16–90). The sex distribution was equal. 94 patients had a single level lesion. 19 fractures were in the thoracic spine; 64 in the thoraco-lumbar (T11-L1) and 29 between L2 and L5. The radiographs were scored using the AO classification by 2 senior orthopaedic trainees. The radiographs were analysed at the Spine Research Laboratory. The results were computed using Stat, a statistical software. Results: The changes were assessed over a mean period of 5.6 mo (range 1–49 mo; 95% CI 4.1–7.1 mo). Weighted kappa score of 0.58 was computed for the primary fracture type and 0.22 for the fracture sub-types. The inter-observer rater agreement was similar to that reported in literature. 7 patients showed a significant collapse. We report the association between the fracture types and the extent of collapse. We have also assessed the association between the medium to long term symptoms, the fracture types and the extent of collapse at the fracture sites and the adjacent disc. Conclusion: Some fracture sub-types are more likely to collapse and cause long term symptoms. Identifying these fractures at the outset would help clarify surgical indications

AIMS. Pure tibial plafond traumatic pathology (excluding trimalleolar fractures) is rare but troublesome, considering the surgical challenges and the long term disability perspective. Treatment involves a wide variety of implants and techniques, and the procedures choice and timing is highly dictated by the soft tissue damage. We designed this study to assess the status of our patients operated with internal, external or combined procedures. METHODS. In a retrospective study, between July 2008 and July 2010 we reviewed 24 patients with available follow-up data. We reviewed the pre- and post-operative imaging available and the immediate follow-up data. A form is currently mailed to the patients to self-evaluate the general physical, mental and employment status, and also the affected limb, using general approved questionnaires. Data from this form is still in process. RESULTS. In this clinic we recorded 24 patients with tibial plafond fractures (17 male, 7 female, 2.43 sex ratio), with ages between 18 and 82 years (average 46.5, median 39 years). According to AO/OTA classification, we noted 8 type A (2 A1, 3 A2, 3 A3) extra-articular tibial fractures, 9 type B (4 B1, 4 B2, 1 B3) intra-articular pilon fractures and 7 type C (3 C1, 1 C2, 3 C3) both epi- and metaphyseal tibial fractures, usually with peroneus fractures at various levels. 10 of these fractures were open, from them 3 type IIIA and 2 IIIB Gustilo-Anderson, and 3 of the patients were politrauma (1 L1 lumbar fracture and distal radius fracture, 1 cranio-cerebral trauma and type I open distal radius fracture and 1 cranio-cerebral trauma). We performed a large array of surgical procedures, usually in emergency, based mainly on the local soft tissue status and both the age and recovery needs of the patient. In old debilitated patients we preferred to use minimal internal osteosynthesis, usually applying a supplementary external fixator or cast. In young active patients we used MIPO techniques in tibial fractures, both with regular or locking-screw plates, repairing also the peroneus in order to preserve the limb length in diaphyseal fractures, and to reconstruct the ankle in lateral malleolus fractures. In cases with severe soft tissue impairment we delayed the definitive osteosynthesis using an external fixator. The short term outcome was good, noting only one septic nonunion, which healed with the appropriate treatment, one calcaneus pin track infection and one deterioration of the external fixator in an alcoholic patient. Data for the mid-term outcome is still under evaluation. CONCLUSIONS. Choosing the appropriate procedure is vital for the outcome. Timing is important, especially in high energy trauma, when the proper surgery performed in emergency allowed us to overcome most of the possible complications. Short term results are encouraging, and the mid-term results will let us know if our attitude was correct

High velocity vertical aircraft ejection seat systems are credited with aircrew survival of 80–95% in modern times. Use of these systems is associated with exposure of the aircrew to vertical acceleeration forces in the order of 15–25G. The rate of application of these forces maybe upto 250G per sceond. Upto 85% of crew ejecting suffer skeletal injury and vertebral fracture is relatively common (20–30%) when diagnosed by plain radiograph. The incidence of subtle spinal injury may not be as apparent. A prospective case series, admitted to QMC Nottingham, from 1996 to 2006 was evaluated. During this interval 26 ejectees from 20 aircraft were admitted to the spinal studies unit for comprehensive examination, evaluation and management. The investigations included radiographs of the whole spine and magnetic resonance Imaging (incorporating T1, T2 weighted and STIR saggital sequences). All ejections occurred within the ejection envelope and occurred at an altitude under 2000 feet (mean 460 feet) and at an airspeed less than 500 knots (mean 275 knots). In this series 6 ejectees (24%) had clinical and radiographic evidence of vetebral compression fractures. These injuries were located in the thoracic and thoracolumbar spine. 4 cases required surgery ( indicated for angular kyphosis greater than 30 degrees, significant spinal canal compromise, greater than 50% or neurological injury. 1 patient had significant neurological compromise, following an AO A3.3 injury involving the L2 vertebra. 11 ejectees (45 %) had MRI evidence of a combined total of 22 occult thoracic and lumbar fractures. The majority of these ejectees with occult injury had multilevel injuries. This study confirms a high incidence if spinal fracture and particularly occult spinal injury. Evidently vertical emergency aircraft ejection imposes major insults on the spinal column. Once, appropriately prioritised, life preservation measures have been undertaken, an early MRI of the spne is mandatory as part of comprehensive patient evaluation. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon

Spinal injuries are among the most devastating injuries related to recreational sport. There are few studies specifically on spinal injuries in horseback riding. The purpose of our study was to determine the factors contributing to horse-riding accidents and to assess the usefulness of wearing protectors while horse riding. All patients with spinal injuries admitted to our unit over a six-year period (1993–1998) were reviewed. Of 957 patients admitted to the National Spinal Injuries Unit from 1993–1998, 25 patients incurred spinal injury while horse riding. Age, sex, occupation and injury details were collected for all patients. All 25 patients were also contacted retrospectively to collect further details in relation to the specifics of the horse-riding event. There were 16 male and 9 female patients with a mean age of 35 years (range 17–61). There were nine cervical fractures/dislocations, eleven thoracic fractures, and eight lumbar fractures. Four patient sustained injuries at more than one level. In relation to spinal cord injury, two patients had complete neurological deficit, a further ten had incomplete lesions. Thirteen patients had no neurological deficit. Surgical intervention was required in eleven patients. Only six riders, all of who were either jockeys or horse trainers, wore back protectors. Of the 19 patients without a back protector there were 5 cervical, 10 thoracic and 6 lumbar injuries. Two patients sustained injuries at more than one level. However, of the six riders wearing a protective jacket there was a completely different fracture pattern level with 4 cervical injuries, only one thoracic injury and on e lumber injury. The variation in injury level between the group wearing protective back supports and those without is noteworthy. While the numbers are too small to draw a significant conclusion it would appear that there is a trend for riders wearing a back protector to suffer less thoracic and lumbar injuries relative to cervical injuries

The changes occurring in ligamentum flavum in lumbar spine stenosis are a matter of long–standing controversy. More recently, some studies showed that the posterior spinal structures, including hypertrophied ligamentum flavum, play a major role in the pathogenesis of the lumbar stenosis. To investigate the pathogenesis of the degenerative changes of the ligamentum flavum occurring in lumbar spine stenosis, yellow ligament cells from patients with lumbar spine stenosis were cultured for the first time and subjected to biochemical, histochemical and immunohistochemical study. Samples of ligamentum flavum were collected from 4 patients undergoing surgery for lumbar stenosis (mean age 47.2 years). Cell cultures were obtained from each patient and maintained in Dulbecco’s modified essential medium-10% fetal calf serum. Cell characterization was histochemically (Gomori’s and von Kossa staining), immunohistochemically (anti-type I, -type II, -type III and -type X collagen, anti-S100 protein, anti-fibronectin, anti-osteonectin and anti-osteocalcin), biochemically (cAMP activity after human parathyroid hormone stimulation) assessed. Samples collected from 2 age-matched patients who underwent surgery for lumbar fractures were used as controls. Stenotic ligamentum flavum cells expressed high levels of alkaline phosphatase activity and produced a mineralized matrix rich in type I, type III and type X collagen, fibronectin, osteonectin, and osteocalcin. Stimulation with parathyroid hormone increased intracellular cAMP concentration. These findings indicate that there was significant evidence of osteoblast-like activity in these cells. Staining for type II and type X collagen, and S-100 protein reflected the proliferation of hypertrophic chondrocyte-like cells, confirmed with the co-localization of alkaline phosphatase and collagen type II. Cultures from control patients showed nor hypertrophic chondrocytic nor osteoblastic features. Our data demonstrated the presence of hypertrophic chondrocytes with an osteoblast-like activity in human stenotic ligamentum flavum. The osteoblast-like activity could have a role in the pathophysiology of the heterotopic ossification of ligamentum flavum in lumbar spine stenosis

Our objective is to perform a prospective study on the efficiency and durability of pain reduction through percutaneous PMMA vertebroplasty in patients with vertebral osteoporotic fractures. We started in March 2002, and up to January 2005 we have performed this technique in 43 patients, 42 female and 1 male, with osteoporotic vertebral fractures. We performed a total of 56 vertebroplasties, 36 lumbar and 20 thoracic. The majority is for the thoracolumbar junction. Patient age went from 56 to 85, with an average of 70,7 years. Cryteria for inclusion in this study have been the following:patients with osteoporosis, preferably with one or two collapsed vertebral bodies, with intractable pain for over 3 months. Exclusion cryteria have been: infection, blood coagulation deficits and mieloradicular compression. Relative exclusion criteria are Fractures over 70% body collapse, Posterior wall fragmentation and Young patient fracture with no prior disease. We perform our PV under local anesthaesia with sedation and in a lateral decubitus position. We preferably use a parapedicular approach for both thoracic and lumbar fractured vertebrae. The material we prefer are the LP2 system or the LCO and we chose Exolent spine for PMMA. We follow a protocol that consists in:bed rest for 2 hours, allowing the patient to sit and have small walks afterwards;Dismissal the following day, with a mild analgesic for the effects of the skin incision;Maintain drug treatment for osteoporosis;Revision on the 2nd and 7th day;New revision at 3, 6 and 12 months. Evaluation of the results was made by defining a pain score: Score 1 corresponds to minor or no improvement in pain. Score 2 corresponds to a medium improvement in pain, with 25 to 50% less drugs required. Score 3 corresponds to a better improvement in pain, with 75 % less drugs required. Score 4 corresponds to complete relief of pain. In our revision, we had a minimum follow-up of 12 months, maximum of 44, and an average of 28 months. We have observed the following results:. - 2 patients with score 1. - 4 patients with score 2. - 32 patients with score 3. - 5 patients with score 4. We can resume this by stating that 90 % of the patients had a relief in pain, and a good result was observed in 75 %. We have had some complications, which consisted in:. - PMMA leakage into the disc in 1 case. - Transitory radicular pain in 1 case. - Hiperthermia in 1 case. - Cannula breakage in 1 case, which was resolved through a small incision. None of these has altered the final result. - Venous leakage in 1 case, which we have considered as the only serious complication. In conclusion, and up to now, we have obtained pain reduction in 90% of the cases; we have prevented collapse of the treated vertebrae, and we have not had collapse of any adjacent vertebrae. It is a technique that may have complications, but results depend on a correct selection of patients

Introduction: Flat Back is a syndrome of sagittal imbalance often associated with back pain commencing in the lumbar region and progressively ascending. It is noted after posterior instrumentation to the lumbosacral junction, with various arthropathies and following compression fractures of the dorsolumbar and lumbar spines. In an attempt to maintain vertical posture, muscle fatigue causes back pain which persists until the condition is rectified. A compensatory pelvic tilt produces hip/hamstring pain and is relieved once lumbar correction is established. The cause of pain is unknown. The aim of this radiological study is to identify abnormal parameters which may contribute to sagittal imbalance and back pain. Methods: Seven fully mobile subjects without fractures served as normal cohorts. Thirty-four consecutive patients aged 18 to 83 years with vertebral compression fractures were studied. There were 28 males. CT scout views of the full length spine in prone and supine positions provided functional scanograms for the Cobb measurement of thoraco-lumbar kyphosis and lumbar lordosis. Degrees of sagittal imbalance were graded as I, II and III, in accordance with the presence of dorsolumbar kyphosis, loss of lumbar lordosis and rigidity in functional views. Previous CT, MRI, Bone Scans were used to exclude other sources of pain such as protruding discs, annular tears, listhesis or un-united fractures. No patients with neurological signs were included. Three sets of measurements were taken:. Dorsolumbar angulation: On prone films, Cobb angle was measured at upper T12 and lower L1 end plates (normal 0°; with standard deviation +3/−3). Lumbosacral angular motion: On functional films, lines were drawn on the upper end plates of L5 and S1. The resulting differences [(+)-(−)] between functional angles were compared with the normal values obtained from the literature (i.e. in excess of 26° of combined motion). The difference between standing lateral functional radiography and the prone/supine scanography was accepted. Sacral inclination: On supine films, the angle between a vertical line (a perpendicular to horizontal baseline) and the upper S1 endplate. Results: There wasÊsignificant reduction in the radiation dose for CT scanograms when compared to conventional radiography: with sparing of bone marrow by 74–80%. The frequency of the abnormal radiological parameters was as follows:. Dorsolumbar angulation: 26 showed (positive) kyphotic angles up to 30°−40°. Lumbosacral angular motion: In view of the spinal rigidity found in most cases, a compensatory excess mobility was expected at 5/1 level, but the opposite was confirmed. Indeed, 27 patiens showed exaggerated (negative) extension shift (of −5°−10°); amongst these 10 were with complete loss of flexion; 12 were with partial flexion (a forward shift of up to 15°), but 5 with full flexion, permitted by a lumbar kyphosis. Sacral inclination: twenty-eight patients showed a shift to a diminished angle of 25°–35° as compared to 35°–55° in 15 control spines. The patients were grouped according to the number of selected abnormal radiological parameters present. The cases were graded: Grade I (1 abnormality) – 2 cases, Grade II -13 cases and Grade III – 19 cases. The threshold for imbalance was (1) at least one severe thoracolumbar compression (or an equivalent combination of multiple minor thoraco-lumbar compression fractures) for D/L kyphosis and (2) a single lumbar fracture with at least 50% compression. Discussion: The cause of pain in post-traumatic sagittal imbalance remains unclear. This study suggests three possible sources of pain, individually or in combination, namely altered angulation at the dorsolumbar junction, reduced motion at L/S level and sacral verticalisation. A more extensive study will be required for verification and interpretation of these preliminary data. It is important to expand the study to variants other than loss of lumbar lordosis

Improvised Explosive Device (IED) attacks on vehicles have been a significant feature of recent conflicts. The Dynamic Response Index (DRI), developed for predicting spinal injury in aircraft ejection, has been adopted for testing vehicles in underbelly blast. Recent papers suggest that DRI is not accurate in blast conditions. We suggest that the distribution of blast and ejection injuries is different. A literature review identified the distribution of spinal fractures in aircraft ejection incidents. A Joint Theatre Trauma Registry search identified victims of mounted IED blast with spinal fractures. The distribution of injuries in the two groups was compared using the Kruskall Wallis test. 329 fractures were identified in ejector seat incidents; 1% cervical, 84% thoracic and 16% lumbar. 245 fractures were identified in victims of mounted blast; 16% cervical, 34% thoracic and 50% lumbar. There was no significant similarity between the two (p=1). There was no statistically significant difference between the distribution of fractures in blast survivors versus fatalities. The difference between blast and ejection injury patterns suggests that injury prediction models for ejection should not be extrapolated to blast mechanisms and that new models need to be developed

Objectives

The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2 calcaneal fractures.

Several studies have reported that remodelling of the spinal canal occurs in lumbar burst fractures following non-operative treatment. Various theories have been proposed for spinal canal remodelling, including the possible effect of the oscillatory pulsations of the subdural space, but no studies have been done to evaluate this effect. In a prospective study between September 1999 and April 2002, we evaluated 17 men and seven women, with a mean age of 35.25 years (19 to 59), who had sustained a burst fracture in the upper lumbar region. The fractures were at the L1 and L2 regions in 14 and 10 patients respectively. The epidural pressure and radiological appearances were initially evaluated approximately two weeks after injury, and again 12 months after injury. All patients were neurologically intact and treated non-operatively. CT evaluation of the initial injury showed a mean initial canal compromise of 49.81% (22.3% to 80%) as measured by mid-sagittal diameter and 13.9% (8.2% to 16.9%) as measured by volumetric assessment, with a mean epidural pressure of 14.56mmHg (2.5 to 30.38). At follow-up 12 months later, the mean epidural pressure was -4.67mmHg (−1.1 to −8.9) and the mean canal compromise as measured by the mid-sagittal diameter and volumetric measurements on CT scan were 24.56% and 8.9% respectively. Our data show that the epidural pressure was raised in acute burst fractures and reverts to normal with remodelling. We can conclude that the raised epidural pressure may be one of the mechanisms that contribute to the remodelling process

Introduction: Spinal fractures are associated with pain, disability, neurological dysfunction and mortality. Osteoporosis and risky leisure time activities are increasing in the population. New treatment options have been introduced. However, only a few international studies have reported its descriptive epidemiology. There are no clear consensuses regarding the choice of operative interventions versus non-operative treatment in patients with thoracolumbar fractures. Treatment is often based on local traditions, skills and experiences. The aim of this nationwide study is to analyse the incidence, the characteristics of the patients, the subsequent development, surgical incidence and mortality rate among hospitalized patients with thoracolumbar fractures in Sweden. Methods: All discharges between 1997 and 2000 with diagnoses of thoracic or lumbar vertebrae fracture according to ICD 10 classification were selected from the National Inpatient Register. Surgery in these patients was categorised by procedure codes indicating spine operations. In order to calculate the risk of patients dying, linkage was performed to the Swedish Death Register using the unique personal identification number. Results: We identified 13, 496 admissions during the study period. This corresponds to an incidence rate of 30 per 100, 000 person-years and the occurrence was stable during 1997 and 2001 for patients younger than 50 years but decreased for patients above 50 years. The incidence of spine surgery among all patients was 1.9 per 100, 000 person-years, ranging from 1.6 per 100, 000 inhabitants per year to 2.6 per 100, 000 in the different region of Sweden. The most common causes of the fracture were falls (53 %) followed by vehicle accidents (37%). Almost two thirds of the patients operated on were men (63 %) and two thirds had lumbar vertebral fractures (66 %). The median age of the patients operated on was 42 years. The median length of stay was eight days. Among those who was operated the 30 days case fatality rate was 0.7 %. Median age for death was 64 years. Operations were less common in women (OR 0.79). The number of patients operated on during the last study year 2001 was significantly increased (OR 1.29). The probability of being operated on was highest in the more urban and densely populated regions of Stockholm and southern Sweden. Discussion: This national study based study showed a stable cumulative incidence of thoracolumbar fractures over the year 1997–2000. However, the two last year of this study an increased incidence of operation was observed. A possible explanation of this finding could be the new percutaneus technique for verterbroplasty. We find it of most importance to further investigate the reasons behind the gender differences in surgical incidence in patients with vertebral fractures

Introduction and Aims: Autologous bone is the preferred method of providing structural support in spinal surgery. The disadvantages are donor site morbidity and limited bone available to reconstitute the anterior column. We evaluated fresh frozen femoral allografts following anterior column reconstruction for lumbar burst fractures with neurological deficit. Method: Twenty-seven patients with neurological deficit ( Frankel grade A(3), B(7), C(16) D (1) due to burst fractures of the dorsolumbar junction were treated with fresh frozen allografts following anterior spinal decompression. The average age was 28 years, and 19 patients sustained the injury following a road traffic accident. The mean pre-operative kyphosis measured 190. A corpectomy was performed in all patients and femoral allografts were positioned by interference fit and the spine stabilised with an anterior rod screw construct. The radiographs were reviewed at three-monthly intervals and the fusion graded by an independent radiologist. Results: The follow-up in 24 patients ranged from 29 to 72 months (mean 43 months) and three patients were excluded due to inadequate follow-up. Allograft incorporation was assessed by criteria of Bridwell et al grade 1 fused with remodelling with cross trabeculae into the adjacent vertebral bodies, grade 11 graft intact, not fully remodelled and incorporated, no lucenies, grade 111 graft intact, but a definite lucency at the top or bottom of the graft, grade 1V not fused with resorption and collapse of graft. The allografts were stable and evidence of graft incorporation and remodelling were observed between eight and 24 months. Grade 1 fusion was seen in 23 patients at two years and subsequent follow-up revealed no fracture, resorption or collapse. The average neurological recovery, which was 1.4 Frankel grades (range 0–2 grades), occurred within seven weeks following surgery (range 11–74 days). Nine patients (37%) made a complete recovery and in four patients (16%) there was no improvement. The mean post-operative kyphosis at two years was 80 (range 2–180). At seven-year follow-up one patient had an asymptomatic grade 11 fusion following secondary infection due to TB which was successfully treated. Conclusion: The indications for the operative treatment of thoracolumbar burst fractures remains controversial. The increased compressive strength of allografts, the large surface of contact, and the stability with instrumentation created a stable construct, which permitted early mobilisation. Allografts were inexpensive biological alternatives to reconstruct the anterior column in burst fractures