Timothy B. Alton

Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases

BACKGROUND CONTEXT Spinal epidural abscess (SEA) is a rare, serious and increasingly frequent diagnosis. Ideal management (medical vs. surgical) remains controversial. PURPOSE The purpose of this study is to assess the impact of risk factors, organisms, location and extent of SEA on neurologic outcome after medical management or surgery in combination with medical management. STUDY DESIGN Retrospective electronic medical record (EMR) review. PATIENT SAMPLE We included 128 consecutive, spontaneous SEA from a single tertiary medical center, from January 2005 to September 11. There were 79 male and 49 female with a mean age of 52.9 years (range, 22-83). OUTCOME MEASURES Patient demographics, presenting complaints, radiographic features, pre/post-treatment neurologic status (ASIA motor score [MS] 0-100), treatment (medical vs. surgical) and clinical follow-up were recorded. Neurologic status was determined before treatment and at last available clinical encounter. Imaging studies reviewed location/extent of pathology. METHODS Inclusion criteria were a diagnosis of a bacterial SEA based on radiographs and/or intraoperative findings, age greater than 18 years, and adequate EMR. Exclusion criteria were postinterventional infections, Potts disease, isolated discitis/osteomyelitis, treatment initiated at an outside facility, and imaging suggestive of a SEA but negative intraoperative findings/cultures. RESULTS The mean follow-up was 241 days. The presenting chief complaint was site-specific pain (100%), subjective fevers (50%), and weakness (47%). In this cohort, 54.7% had lumbar, 39.1% thoracic, 35.9% cervical, and 23.4% sacral involvement spanning an average of 3.85 disc levels. There were 36% ventral, 41% dorsal, and 23% circumferential infections. Risk factors included a history of IV drug abuse (39.1%), diabetes mellitus (21.9%), and no risk factors (22.7%). Pathogens were methicillin-sensitive Staphylococcus aureus (40%) and methicillin-resistance S aureus (30%). Location, SEA extent, and pathogen did not impact MS recovery. Fifty-one patients were treated with antibiotics alone (group 1), 77 with surgery and antibiotics (group 2). Within group 1, 21 patients (41%) failed medical management (progressive MS loss or worsening pain) requiring delayed surgery (group 3). Irrespective of treatment, MS improved by 3.37 points. Thirty patients had successful medical management (MS: pretreatment, 96.5; post-treatment, 96.8). Twenty-one patients failed medical therapy (41%; MS: pretreatment, 99.86, decreasing to 76.2 [mean change, -23.67 points], postoperative improvement to 85.0; net deterioration, -14.86 points). This is significantly worse than the mean improvement of immediate surgery (group 2; MS: pretreatment, 80.32; post-treatment, 89.84; recovery, 9.52 points). Diabetes mellitus, C-reactive protein greater than 115, white blood count greater than 12.5, and positive blood cultures predict medical failure: None of four parameters, 8.3% failure; one parameter, 35.4% failure; two parameters, 40.2% failure; and three or more parameters, 76.9% failure. CONCLUSION Early surgery improves neurologic outcomes compared with surgical treatment delayed by a trial of medical management. More than 41% of patients treated medically failed management and required surgical decompression. Diabetes, C-reactive protein greater than 115, white blood count greater than 12.5, and bacteremia predict failure of medical management. If a SEA is to be treated medically, great caution and vigilance must be maintained. Otherwise, early surgical decompression, irrigation, and debridement should be the mainstay of treatment.

Do Anchor Density or Pedicle Screw Density Correlate With Short-Term Outcome Measures in Adolescent Idiopathic Scoliosis Surgery?

Study Design. Retrospective review. Objective. Determine if factors under surgeon control (anchor density or pedicle screw density) or those not under surgeon control (curve magnitude, levels requiring fusion, and curve flexibility) correlate with standard, short-term quality and outcome measures for adolescent idiopathic scoliosis. Summary of Background Data. Pedicle screw fixation has revolutionized posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis and seems to provide greater radiographical coronal plane curve correction than less expensive constructs. Other clinically relevant improvements in outcome have been difficult to demonstrate. Methods. Retrospective review of 119 posterior spinal instrumentation and fusion cases for adolescent idiopathic scoliosis by 4 surgeons at 1 institution. Average follow-up was 586.7 days. Outcome measures were main thoracic curve correction, complications, reoperations, infection, intensive care unit days, length of stay, estimated blood loss, transfusion, procedure time, implant charges, and total hospital charges. “Surgeon-dependent” variables were implant density (fixation/instrumented level) and pedicle coefficient (implant density × percentage of anchors that are pedicle screws). “Surgeon-independent” variables were main thoracic curve magnitude, main thoracic curve flexibility, and levels fused. Correlations were estimated using Pearson correlation coefficients. One-way analysis of variance was used to estimate the effect of “type of surgeon” or “surgeon” on surgeon-dependent variables. Results. Complications, reoperations, and infections did not correlate with surgeon-dependent or surgeon-independent variables. Main thoracic curve correction correlated strongly with curve flexibility (correlation coefficient [cc] = 0.4089, P < 0.0001). Surgeon-independent variables were levels fused correlated significantly with procedure time (cc = 0.610, P < 0.001), hospital charges (cc = 0.309, P < 0.001), hospital length of stay (cc = 0.366 [P < 0.001]), implant charges (cc = 0.199, P < 0.047), and estimated blood loss (cc = 0.243, P < 0.013). Surgeon-dependent variables were implant density significantly correlated with implant charges (cc = 0.243, P < 0.015) and inversely with length of stay (cc = −0.236, P < 0.015). Pedicle coefficient was not significantly correlated with any outcome measure. Conclusion. Levels fused, a surgeon-independent variable, had the most consistently strong correlations with standard short-term quality indicators. With physician grading by payers largely dependent on easily measured outcomes from medical records, hospital and billing records, physicians need to be aware of the surgeon-dependent and surgeon-independent variables that may affect their outcomes and cost-effectiveness profile. Level of Evidence: 3

Upper cervical spine trauma

Injuries to the upper cervical spine are potentially lethal; thus, full characterization of the injuries requires an accurate history and physical examination, and management requires an in-depth understanding of the radiographic projection of the craniocervical complex. Occipital condyle fractures may represent major ligament avulsions and may be highly unstable, requiring surgery. Craniocervical dissociation results from disruption of the primary osseoligamentous stabilizers between the occiput and C2. Dynamic fluoroscopy can differentiate the subtypes of craniocervical dissociation and help guide treatment. Management of atlas fractures is dictated by transverse alar ligament integrity. Atlantoaxial dislocations are rotated, translated, or distracted and are treated with a rigid cervical orthosis or fusion. Treatment of odontoid fractures is controversial and dictated by fracture characteristics, patient comorbidities, and radiographic findings. Hangman’s fractures of the axis are rarely treated surgically, but atypical patterns and displaced fractures may cause neurologic injury and should be reduced and fused. Management of injuries to the craniocervical junction remains challenging, but good outcomes can be achieved with a comprehensive plan that consists of accurate and timely diagnosis and stabilization of the craniocervical junction.

Classifications in Brief: Young and Burgess Classification of Pelvic Ring Injuries

To aid in rapid and appropriate treatment of pelvic ring injuries, numerous attempts to classify these injuries have been made. In 1938 Watson-Jones proposed a schema based primarily on fracture location [26]. Huittinen and Slatis noted the relationship between the direction of impact and the resulting pelvic injury pattern [6] and Trunkey et al. [25] introduced the concept of stability. Location and magnitude of the applied force, either high or low energy, have been recognized as important factors responsible for pelvic injuries [6, 7]. Stability of the ring also was identified as a critical component of pelvic ring management [10]. Pennal et al. [14] were the first to systematically describe the force vector responsible for pelvic ring injury as AP compression (APC), lateral compression (LC), or vertical shear (VS). Tile et al. [23] added the concept of stability (ie, stable, vertically stable but rotationally unstable, vertically and rotationally unstable). Acetabular fractures were considered separately in the classifications of Tile et al. (comprehensive classification) [23] and Young et al. (Young and Burgess classification) [27]. In 1986, Young et al. described 142 patients with pelvic ring injuries and classified their injuries mechanistically [27] (Fig. 1). Using AP pelvic radiographs, pelvic injuries (fractures and joint disruptions from ligamentous injuries) were identified. These injuries appeared in patterns correlating with the direction and location of applied force. The authors cited the necessity for rapid and accurate diagnosis of pelvic injuries and correction of pelvic deformity as essential aspects of the resuscitation and treatment of patients with pelvic ring injuries. By understanding that APC injuries result in external rotation of the hemipelvis and learning to identify this deformity on rapidly obtained AP pelvic radiographs, providers learned to apply circumferential resuscitative splints (pelvic binders or pelvic sheets) to correct this deformity, decrease intrapelvic volume, and aid in patient resuscitation. Additionally, by recognizing vertical shear injuries, traction can be applied to reduce the proximally displaced hemipelvis. These concepts were articulated by Young et al. [27] and continue to be a cornerstone in the evaluation and treatment of patients with pelvic ring injuries.

Classifications in Brief: Letournel Classification for Acetabular Fractures

In December 1961, Letournel [10] published his original series on acetabular fracture classification and operative management. Before that time, acetabular fractures were classified as those associated with posterior hip dislocation and those associated with central hip dislocation. Many were treated without surgery, resulting in poor articular congruity of the hip. Citing an increasing incidence of these injuries with the increasing number of automobiles on the road and ‘‘disappointment with the closed treatment of these fractures, we [Judet et al.] decided to try open reduction’’ [8]. Their series included 173 patients, 129 of whom were treated surgically. Pelvic radiographs were correlated with surgical findings. The anterior and posterior columns of the acetabulum were defined based on the radiographic projections of normal and fractured acetabula on three views: AP pelvic film and internal and external 45 obliques (Judet views). Seven acetabular fracture patterns were described, divided into elementary and associated patterns. In 1980, using radiographic and surgical data from 647 acetabular fractures, of which 582 had undergone surgical fixation, Letournel [11] confirmed and updated his original description [8]. He divided acetabular fractures into 10 subtypes, five elementary patterns and five associated patterns (including more than one elementary pattern). Elementary patterns included posterior wall fractures, posterior column, anterior column, anterior wall, and transverse fracture patterns. Associated patterns include T-shaped, posterior column and posterior wall, transverse and posterior wall, anterior and hemitransverse, and fractures of both columns [11] (Fig. 1).

Is there a difference in neurologic outcome in medical versus early operative management of cervical epidural abscesses

BACKGROUND CONTEXT The ideal management of cervical spine epidural abscess (CSEA), medical versus surgical, is controversial. The medical failure rate and neurologic consequences of delayed surgery are not known. PURPOSE The purpose of this study is to assess the neurologic outcome of patients with CSEA managed medically or with early surgical intervention and to identify the risk factors for medical failure and the consequences of delayed surgery. STUDY DESIGN/SETTING Retrospective electronic medical record (EMR) review. PATIENT SAMPLE Sixty-two patients with spontaneous CSEA, confirmed with advanced imaging, from a single tertiary medical center from January 5 to September 11. OUTCOME MEASURES Patient data were collected from the EMR with motor scores (MS) (American Spinal Injury Association 0-100) recorded pre/posttreatment. Three treatment groups emerged: medical without surgery, early surgery, and those initially managed medically but failed requiring delayed surgery. METHODS Inclusion criteria: spontaneous CSEA based on imaging and intraoperative findings when available, age >18 years, and adequate EMR documentation of the medical decision-making process. Exclusion criteria: postoperative infections, Pott disease, isolated discitis/osteomyelitis, and patients with imaging findings suggestive of CSEA but negative intraoperative findings and cultures. RESULTS Of the 62 patients included, 6 were successfully managed medically (Group 1) with MS increase of 2.3 points (standard deviation [SD] 4.4). Thirty-eight patients were treated with early surgery (Group 2) (average time to operating room 24.4 hours [SD 19.2] with average MS increase 11.89 points [SD 19.5]). Eighteen failed medical management (Group 3) requiring delayed surgery (time to OR 7.02 days [SD 5.33]) with a net MS drop of 15.89 (SD 24.9). The medical failure rate was 75%. MS change between early and delayed surgery was significant (p<.001) favoring early surgery. Risk factors and laboratory data did not predict medical failure or posttreatment MS because of the high number of medical failures when abscess involves the cervical epidural space. CONCLUSIONS Early surgery results in improved posttreatment MS compared with medical failure and delayed surgery. In our patients, the failure rate of medical management was high, 75%. Based on our results, we recommend early surgical decompression for all CSEA.

In Brief: Classifications in Brief: Brooker Classification of Heterotopic Ossification After Total Hip Arthroplasty

THA is a frequently performed surgery for the treatment of patients with osteoarthritis, rheumatoid arthritis, avascular necrosis, developmental dysplasia, and many other forms of hip pathology. Heterotopic ossification (HO) is a common complication after THA with a frequency of 26% to 41% reported in recent studies [2, 20, 21]. The majority of HO is not clinically important, but severe HO may lead to decreased hip ROM [12] and increased pain [7]. Multiple different classification schemes have been proposed to describe the degree of HO after THA, including those by Brooker et al. [3], Hamblen et al. [9], DeLee et al. [5], and Kjaersgaard-Andersen et al. [11] as well as by Arcq [1] within the German literature. All of the classification systems use plain radiographs in at least the AP plane, but some make use of other radiographic views as well. The Brooker classification system was one of the earliest systems described and remains very widely used in contemporary literature. Some groups have suggested modifications or additions to the Brooker system with the goal of improving consistency and predictability [6, 19, 23], whereas others have focused on simplifying the Brooker system to improve communication and reproducibility [22]. Although these authors have argued that their revisions demonstrate an improvement over the Brooker classification, the original Brooker classification remains a commonly used system for classifying HO after THA.

Classifications In Brief: The Gartland Classification of Supracondylar Humerus Fractures

Supracondylar humerus fractures are the most common elbow injury in pediatric patients [24]. During the 1950s, these injuries were called the ‘‘misunderstood fracture,’’ as such injuries often resulted in bony deformity and Volkmann’s contracture [12]. In 1959, Gartland described a simple classification scheme to reemphasize principles underlying treatment of patients with a supracondylar humerus fracture and discussed a method of injury management that has proven to be practical and effective with time [12]. Supercondylar humerus fractures occur proximal to the articular surface of the distal humerus and may be transverse, oblique, or jagged. Gartland described a rotatory and translational deformity, with posterior displacement (extension) of the distal fragment occurring most often [12]. He described three types of extension injury based on degree of displacement: type I, nondisplaced; type II, moderately displaced; and type III, severely displaced injury, and he considered flexion-type injuries separately [12]. Purpose

Pediatric cervical spondylolysis and American football

BACKGROUND CONTEXT Cervical spondylolysis (CS) is a rare condition and is even more uncommon in pediatric patients. It is characterized by a disruption of the articular mass at the junction of the superior and inferior facet joints and often is diagnosed incidentally. The C6 level is most commonly involved, and the cause of CS remains unknown. There are no recommendations in the literature regarding activity modification in patients with CS and no discussion as to risks of participation in American football or other contact sports. PURPOSE To report a case of C6 bilateral cervical spondylolysis with bicuspid spinous process and to discuss radiographic/clinical findings and issues related to participation in contact sports and minimizing the risk of spinal cord injury. STUDY DESIGN/SETTING Case report with 6 months clinical/radiographic follow-up METHODS Radiographic description, clinical findings, and current review of the literature. RESULTS A pediatric patient presented with a bilateral C6 cervical spondylolysis and bicuspid spinous process after an American football-related minor cervical spine trauma. Findings on radiographs indicated that the spondylolysis appeared to be chronic in nature, without evidence of instability. The patient and his family were educated on ways to decrease the risk of spinal cord injury with contact sports, after which the patient was allowed to participate fully in sports without restrictions or adverse events. CONCLUSION Pediatric cervical spondylolysis is a rare condition, the cause of which remains debated. Although there is theoretical risk, more than 1.5 million youth participate in American football annually, and there have been no reported cases of significant spinal cord injury in patients with CS from football or other contact sports.

Prognostic Value of Computed Tomography Classification Systems for Intra-articular Calcaneus Fractures

Background: There are several published computed tomography (CT) classification systems for calcaneus fractures, each validated by a different standard. The goal of this study was to measure which system would best predict clinical outcomes as measured by a widely used and validated musculoskeletal health status questionnaire. Methods: Forty-nine patients with isolated intra-articular joint depression calcaneus fractures more than 2 years after treatment were identified. All had preoperative CT studies and were treated with open reduction and plate fixation using a lateral extensile approach. Four different blinded reviewers classified injuries according to the CT classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders. Functional outcomes evaluated with a Musculoskeletal Functional Assessment (MFA). The mean follow-up was 4.3 years. Results: The mean MFA score was 15.7 (SD = 11.6), which is not significantly different from published values for midfoot injuries, hindfoot injuries, or both, 1 year after injury (mean = 22.1, SD = 18.4). The classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders, the number of fragments of the posterior facet, and payer status were not significantly associated with outcome as determined by the MFA. The Sanders classification trended toward significance. Anterior process comminution and surgeon’s overall impression of severity were significantly associated with functional outcome. Conclusions: The amount of anterior process comminution was an important determinant of functional outcome with increasing anterior process comminution significantly associated with worsened functional outcome (P = .04). In addition, the surgeon’s overall impression of severity of injury was predictive of functional outcome (P = .02), as determined by MFA. Level of Evidence: Level III, comparative series.