Howard M. Place

Sacral insufficiency fractures in rheumatoid arthritis.

Methods All patients with rheumatoid arthritis (RA) attending an outpatient rheumatology clinic at a major military medical center over 6 years were included in follow-up for the development and subsequent course of sacral insufficiency fractures. Results Sacral insufficiency fractures developed in 4 of 386 patients. Consistent with the literature, patients were female, elderly, and/or postmenopausal, had severe or long-standing disease, and were taking corticosteroids. The correct diagnosis was initially delayed because radiographs were normal but was later established with bone scan and sacral computerized tomography. Each patient improved with calcitonin and/or physical therapy over time. Conclusions Patients with RA represent a unique subgroup predisposed to insufficiency fractures because of multiple osteoporotic risk factors. Patients who have RA and acute low back or buttock pain should be evaluated aggressively for sacral insufficiency fractures with bone and/or computed tomography scans regardless of normal plain radiographs.

A Comparison of Early Clinical and Radiographic Complications of Iliac Screw Fixation Versus S2 Alar Iliac (S2AI) Fixation in the Adult and Pediatric Populations.

Study Design: Retrospective chart review. Objective: To compare short-term clinical and radiographic complications between iliac screw (IS) and S2 alar-iliac (S2AI) screw fixation techniques in the adult and pediatric populations. Summary of Background Data: Pelvic fixation with lumbosacral implants is in widespread practice with numerous indications. Several techniques for spinopelvic fixation have been described in the literature. Although the iliac screw technique is widely practiced, it presents several challenges, including the use of connectors, more lateral surgical dissection, and some complaints of pain over the posterior pelvis. The S2AI method has recently been proposed as an alternative technique that minimizes these complications. Methods: We retrospectively reviewed the charts of 65 adult patients (43 IS, 22 S2AI) and 55 pediatric patients (40 IS/unit rod, 15 S2AI) in a consecutive series who underwent spinopelvic fixation. Acute, spinopelvic implant-related, and delayed complications, including persistent pain over the gluteal region occurring longer than 3 months postoperatively, were recorded from both clinical and radiographic encounters. Statistical analyses were performed among the adult and pediatric group, respectively, as well as a pooled cohort. Results: The adult cohort found an 18.6% absolute risk reduction (ARR) in implant loosening (P=0.029) and a 21.1% ARR (P=0.05) in late pain with the S2AI method. In the pediatric population, the S2AI method demonstrated a 22.2% ARR (P=0.049) in both occurrence of revision surgery secondary to spinopelvic implant failure and late pain. In the pooled cohort, the S2AI method had a 13% ARR (P=0.033) in acute infections, 18.1% ARR (P=0.003) in implant loosening, 14.5% ARR (P=0.009) in revision surgery, 18.7% ARR (P=0.015) in late pain, and a 10.8% ARR (P=0.031) in delayed wound issues. Conclusions: The S2AI technique is associated with significantly less clinical and radiographic complications in both the pediatric and adult populations when compared with the iliac screws technique. Level of Evidence: Level III.

Stabilization of thoracic spine fractures resulting in complete paraplegia. A long-term retrospective analysis.

Study Design. The impact of surgical stabilization on initial rehabilitation and complications in patients with traumatic thoracic level paraplegia was investigated. One hundred thirteen patient records were retrospectively reviewed. Summary of Background Data. Forty-six patients had been treated with surgical stabilization and fusion. Nineteen patients had been treated by laminectomy alone. Forty-eight patients had been treated nonoperatively. The most common mechanism of injury was a motor vehicle accident (52.6%). The mean follow-up was 8.4 years. Methods. All inpatient and outpatient records at Craig Hospital were reviewed for patients who had sustained a thoracic spine fracture (T2–T9) that resulted in complete paraplegia (Frankel A). All patients were followed for a minimum of 5 years. Data were collected regarding initial length of inpatient rehabilitation, as well as early and late complications that affected rehabilitation and function during follow-up. This information was analyzed by treatment group. Results. There was a statistically significant difference in the length of initial rehabilitation days between the surgically stabilized group and the laminectomy-only group. There was a trend toward fewer in-patient rehabilitation days between the surgically stabilized group and the nonoperatively treated group. The surgically treated group had twice as many complications as the nonoperative group. Conclusions. The surgical stabilization of thoracic (T2–T9) spine fractures with complete paraplegia tends to decrease initial rehabilitation days but is associated with increased overall complications. The treatment of this patient group clearly must be individualized.

Face tissue pressure in prone positioning: a comparison of three face pillows while in the prone position for spinal surgery.

Study Design. This is a prospective, randomized study. Objective. The purpose was to compare the tissue-pillow interface pressures at the forehead and chin in patients positioned in the prone fashion for spinal surgery on each of 3 facial positioners. Summary of Background Data. Facial pressure ulcers have been infrequently observed after spinal surgery requiring prone positioning. This requires the use of a specially designed head positioner to maintain spinal alignment and to allow space for the endotracheal tube. Methods. We enrolled 66 consecutive elective thoracic and/or lumbar surgery patients from 18 to 65 years of age. Patients were randomized on entry into the study to 1 of 3 positioners. Facial tissue pressures were measured at the patient’s forehead and chin at times 0, 5, 15, and 60 minutes of positioning. The integrity of the patient’s skin was recorded and classified at the end of surgery. Results. The pressures measured for the Dupaco positioner were lower at all time points at both the forehead and the chin in comparison with the other 2 positioners (P < 0.05). The ROHO and the OSI positioners created similar chin pressures at all time points (P > 0.05). The pressures at the forehead for the ROHO positioner were significantly less than those for the OSI positioner at all time points (P < 0.05). Ten patients on the OSI positioner had pressure ulcers at the end of the procedure. Conclusion. The Dupaco ProneView Protective Helmet System is superior to both the OSI and the ROHO positioners in decreasing forehead and chin tissue interface pressures during prone position surgery.

Hypomagnesemia in postoperative spine fusion patients.

Study Design This was a retrospective review of 49 consecutive patient charts and a prospective study of 44 consecutive patients who underwent spinal fusion. Objective To determine the incidence and clinical significance of hypomagnesemia after spinal fusion. Summary of Background Data Hypomagnesemia may be seen in 61% of patients in postoperative intensive care and may be associated with increased mortality. However, symptomatic hypomagnesemia is rare. Methods A retrospective review of the charts of 49 consecutive patients who underwent spine fusion was completed to determine postoperative magnesium levels. Twenty‐seven patients with postoperative hypomagnesemia received routine magnesium replacement regardless of symptoms. Forty‐four patients who underwent spine fusion were studied prospectively for post‐operative hypomagnesemia. Prospectively studied observational patients who developed hypomagnesemia were treated only when clinical signs or symptoms of magnesium deficiency occurred. Results Postoperative hypomagnesemia occurred in 28 of 49 retrospectively studied patients who underwent spine fusion (57%) and 38 of 44 prospectively studied patients who underwent spine fusion (86%). Symptoms associated with hypomagnesemia developed in three of 44 prospectively studied and two of 49 retrospectively studied patients who underwent spine fusion (7% and 4%, respectively). The combined incidence for symptomatic hypomagnesemia was five of 93 patients (5.4%). The majority of patients from the prospective study with postoperative hypomagnesemia were asymptomatic, and their magnesium levels returned to normal within 4 days, with or without treatment. Conclusions This study confirmed a high incidence of hypomagnesemia in patients who underwent spine fusion, although only 5.4% developed clinical signs or symptoms of magnesium deficiency. The cause of hypomagnesemia remains speculative.

Acute Complications After Adult Spinal Deformity Surgery in Patients Aged 70 Years and Older.

Study Design/Setting:This report is a retrospective case series that examined the acute complications of patients aged 70 years and older undergoing spinal deformity surgery that required fusion of at least 6 levels. Objective:To determine the acute complications that patients in the eighth decade of their life experience after spinal reconstructive surgery, and how these complication rates compare with other patient populations undergoing similar procedures. Summary of Background Data:As the mean age of the United States population rises, more older patients with painful spinal deformities can be expected. Although there are similar studies in the literature examining acute complications of patients undergoing major spinal deformity surgery, the complication rates of this unique patient population have not been adequately studied. Methods:Twenty patients had complete medical records with at least 6 months of follow-up. All the 20 patients underwent instrumented posterior spinal fusions performed by the same surgeon. Comorbidities, weighted comorbidity index, duration, number of hospital days, estimated blood loss, intensive care unit days, American Society of Anesthesiologist score, and intraoperative and postoperative complications were recorded. Results:The mean age of our patient cohort was 76.6 years (range, 70–84 y). Patients had an average of 4 comorbidities and an American Society of Anesthesiologist score of 2.7. Although the group of patients had a large number of comorbidities, their weighted comorbidity index, according to Charlson and colleagues, was fairly low at 1.05 (range, 0–4). All of the patients were fused at least 6 levels, with the average being 10.75 (range, 6–15). Ninety-five percent of patients experienced a complication of some type. Nine major complications occurred in 7 patients. Conclusions:Spinal deformity surgery in patients at any age has associated risks. These risks are believed to increase with age and the complexity of the procedure. Our results show that, although the risks of major complications are significant, the risk is not greater than in a younger population undergoing the similar procedures. We feel that age alone should not be a contraindication for patients in their eighth decade of life who are incapacitated by their painful spinal deformity.

Vacuum-assisted Wound Closure in Postoperative Spinal Wound Infection

Combined with antibiotic therapy, vacuum-assisted wound closure may help reduce the need for serial irrigation and debridement surgery, contributing to a decrease in overall hospital stay.

Cervical Spine Subluxation in Marfan Syndrome: A Case Report

Subluxation of the cervical spine may occur in patients secondary to trauma. Patients with Down syndrome and rheumatoid arthritis can have spontaneous cervical spine subluxation. Although cervical spine abnormalities are common in patients with Marfan syndrome, clinical problems are rare1. Lumbar subluxation is rarely seen in patients with this condition2 and, in an extensive review of cervical spine involvement in patients with Marfan syndrome, Hobbs et al. noted no cases of cervical subluxation1. We describe the clinical features and surgical treatment of a patient with Marfan syndrome who had progressive multilevel cervical subluxation. The patient was informed that information concerning this case would be submitted for publication. Athirteen-year-and-four-month-old boy presented to the Spine Service with right-sided neck pain associated with decreased range of motion. There was no history of trauma or recent illness. The medical history was unremarkable. The range of neck motion was flexion to 45°, extension to 10°, left axial rotation to 60°, and right axial rotation to 20°. The patient had mild upper cervical spine tenderness and had normal findings on neurological examination. Initial radiographic examination revealed anterior subluxation of C2 on C3, with marked segmental kyphosis (Fig. 1). Magnetic resonance imaging revealed disc-space changes at C2-C3 that were consistent with infection. The facet joints were aligned. Given the patients complaints of pain and the finding of cervical subluxation on plain radiographs, the patient was admitted for evaluation and treatment. Computed tomography revealed no evidence of fracture. A bone scan with SPECT (single photon emission computed tomography) imaging showed slight posterior uptake at C2-C3 consistent with trauma. The findings of the laboratory evaluation were unremarkable and included a normal white blood-cell count, erythrocyte sedimentation rate, and C-reactive protein level. The patient was managed with skeletal traction with use of tongs, with easy …

Cervical spine injury in a boxer: should mandatory screening be instituted?

Cervical spine fracture is a rare, yet potentially catastrophic complication associated with boxing. Neurologic deficits, ocular injuries, or other traumatic musculoskeletal injuries have been commonly reported. Symptoms of cervical spine injury may be minimal or absent. Cervical spine fracture may be undiagnosed and unreported in boxers with presumed soft-tissue injury to the head and neck. We describe a young athlete who sustained a transient spinal cord injury while boxing, which required a cervical spine fusion and postoperative immobilization in a halo vest. This athlete also had an os odontoideum, which placed him at significant risk for such an injury. Pre- and postparticipation screening of the cervical spine should be considered in all boxers.

Evaluation of a new spine classification system, does it accurately predict treatment?

Study Design The Thoracolumbar Injury Severity Score (TLISS) was introduced as a novel classifications system. Its aim was to simplify classification of thoracolumbar fractures, grade their severity in an ordinal manner as a guide to management. This study attempted to validate the TLISS as a guide to management. Objective To evaluate the TLISS as a tool for guiding management of thoracolumbar fractures using the outcomes of 97 previously treated spinal fracture. Summary of Background Data The TLISS was proposed as a tool for guidance of the management of thoracolumbar fractures to aid the surgeon in choosing management. Method Ninety-seven sequential traumatic thoracolumbar fractures were retrospectively reviewed for their management and outcomes. The presenting clinical information had all personal identifiers removed and the fractures were reevaluated by the treating physician using the TLISS. Eighty-one patients had received management that agreed with the suggested management of the TLISS. Nine patients had a score of 4. Seven patients received management that disagreed with the TLISS. Variables affecting the management that differed from the management suggested by the TLISS were identified in each patient and assessed. Result Of the 97 patients identified, 81 had received management that agreed with the suggested management of the TLISS. Of the 16 remaining patients, 3 patients scored a 3 or less and received an operation, 1 of which, failed conservative management. Four scored a 5 or more and were managed conservatively, none with known failure. Nine patients scored the ambiguous score of 4. Of these, 4 were managed operatively and 5 nonoperatively. Conclusions As a management tool, the TLISS seems to consistently suggest treatment consistent with past treatment recommendations. Multilevel contiguous fractures and extension injuries in the ankylosed thoracic spine appear to be the most consistent exceptions to the TLISS guidelines.