The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 ...medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons.
An organizational model is presented based on case centralization in hub hospitals and early management of surgical cases to reduce hospital stay. Data from all the patients admitted for emergency spinal surgery from the beginning of the outbreak were prospectively collected and compared to data from patients admitted for the same reason in the same time span in the previous year, and treated by the same integrated team.
A total of 19 patients (11 males and eight females, with a mean age of 49.9 years (14 to 83)) were admitted either for vertebral fracture or spinal cord compression in a 19-day period, compared to the ten admitted in the previous year. No COVID-19 patients were treated. The mean time between admission and surgery was 1.7 days, significantly lower than 6.8 days the previous year (p < 0.001).
The structural organization and the management protocol we describe allowed us to reduce the time to surgery and ultimately hospital stay, thereby maximizing the already stretched medical resources available. We hope that our early experience can be of value to the medical communities that will soon be in the same emergency situation. Cite this article:
2020;102-B(6):671-676.
•150 patients with sacral fractures were independently classified according to the AOSpine sacral fractures classification.•The intraobserver reproducibility for the whole group was substantial ...(κ=0.72). The interobserver reliability was moderate, with a κ=0.57.•No significant differences in agreement were found comparing surgeon expertise (Pelvic vs spine Surgeons) or experience.•Our findings confirmed the reliability and reproducibility of the AOSpine sacral fractures classification in clinical practice.
Retrospective Cohort Study
The AOSpine Sacral Classification System was proposed as a comprehensive and universally accepted new classification for Sacral Fractures, and was recently internally validated. However, an external, independent and multidisciplinary reports on validation of this classification is lacking. Aim of the present study is to analyze the interobserver reliability and intraobserver reproducibility of the AOSpine Sacral Classification System for Sacral Fractures between orthopedic spinal and pelvic surgeons with different levels of experience.
Our institutional database was searched to retrieve patients with acute, traumatic sacral injury admitted from June 2017 to June 2020. For each patients, X-Rays and CT scans were collected. Three Orthopedic Pelvic Surgeons (Group A) and three Spine Surgeons (Group B), with different level of experience (Junior, 〈 5 years; Middle, 5–10 years; Expert 〉 10 years) independently classified all the sacral fractures included in the dataset, with two separate evaluation three weeks apart. Both intra and interobserver reliability were calculated with k-coefficient.
Overall, 150 patients were included in the final dataset, for a total of 1800 different assessments, with all the subtypes reported. The intraobserver reproducibility for the whole group was substantial (κ=0.72). Overall, the interobserver reliability was moderate, with a κ=0.57. When only fracture type was taken in account, the κ value became substantial (κ=0.62). No significant differences were found comparing group A and group B (0.55 vs κ 0.55, p>0.05). No significant differences according to surgeon's experience were found; however, the κ value was slightly lower among the junior surgeons.
Our findings confirmed the reliability and reproducibility of this classification in clinical practice. In the current study the surgeon's expertise (pelvic and spinal trauma) and the level of experience does not influence the reliability of the classification system.
Abstract Background Aim of the study was to evaluate degenerative lumbar facet-joints changes after percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar fractures. Materials and ...methods Thirty patients underwent short PPSF without fusion. CT-scan was performed in the pre- and post-operative time at four, eight and 12 months. The six zygapophyseal joints adjacent the fracture's level were evaluated. Results At four months patients showed no differences between pre- and post-operative joint radiographic aspect. At eight and 12 months, CT-scan demonstrated a progressive degeneration only in the middle joints respectively in 21.42% and in 76.92% of the cases. All 10 disrupted facet joints showed progressive degenerative changes at eight and 12 months. Conclusion Lumbar percutaneous fixation without fusion induces little degenerations essentially collocated in the middle joints close to fracture level at eight and 12 months. In the proximal and distal joints adjacent the screws degenerative changes can be seen only when associated to pedicle-screw encroachment. Level of evidence Level IV retrospective study.
Introduction
Aim of the study was to evaluate the effectiveness of facet joints injections in lumbar facet syndrome correlating clinical results to the sagittal contour of the spine.
Methods
Facet ...joints degree degeneration was evaluated using MRI according to Fujiwara classification. Sagittal contour of the spine was evaluated according to Roussouly classification. The clinical results were evaluated with visual analog scale (VAS) at regular intervals.
Results
Twenty-eight (70 %) of the 40 patients had clinical symptoms improvement, 12 (30 %) showed no benefit. There was a statistical significant correlation between postoperative VAS value improvement and Roussouly spine type 1 and 3 (
p
= 0.003). The benefit was more durable in patients with grade 2 or 3 degeneration.
Conclusions
Facet joints injections have a more effective diagnostic than therapeutic value. The procedure could, however, give a temporary pain relief in cases with an overload of the facet joints due to lumbar hyperlordosis.
Abstract Background Treatment of A3 thoraco-lumbar and lumbar spinal fractures nowadays remains a controversial issue. Percutaneous techniques are becoming very popular in the last few years to ...reduce the approach-related morbidity associated with conventional techniques. Hypothesis Purpose of the study was to analyze the clinical and radiological outcome of patients who underwent percutaneous posterior fixation without fusion for the treatment of thoraco-lumbar and lumbar A3 fractures. Materials and methods Sixty-three patients, having sustained a single-level thoraco-lumbar fracture, underwent short segment percutaneous instrumentation and were retrospectively analyzed. sagittal index (SI) was calculated in all patients. Clinical and functional outcome were evaluated by Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form General Health Status (SF-36). Results Average operative blood loss was 82 mL (50–320). Mean pre-operative SI in the thoraco-lumbar segment was 13.3° decreased to 5.8° in the immediate postoperative with a mean deformity correction of 7.5. Mean pre-operative SI in the lumbar segment was 16.5° decreased to 11.3° in the immediate postoperative with a mean deformity correction of 5.2. Not statistically significant correction loss was registered at 1-year minimum follow-up. Constant clinical conditions improvement in the examined patients was observed. Conclusion Percutaneous pedicle screw fixation for A3 thoraco-lumbar and lumbar spinal fractures is a reliable and safe procedure. Level of evidence Level IV. Retrospective study.
Purpose
The aim of the study was to evaluate clinical and radiographic outcome of patients treated with a modified Grob technique analysing the advantages related to increased mechanical stability.
...Methods
30 patients that underwent “in situ” fusion for L5-S1 spondylolisthesis were evaluated. All patients presented a low-dysplastic developmental L5-S1 spondylolisthesis. Patients were divided into two groups: A, in which L5-S1 pedicle instrumentation associated with transsacral screw fixation was performed, and B, in which L5-S1 pedicle instrumentation associated with a posterolateral interbody fusion (PLIF) was performed.
Results
Patients treated with transdiscal L5-S1 fixation observed a faster resolution of the symptoms and a more rapid return to daily activities, especially at 3–6 months’ follow-up. The technique is reliable in giving an optimal mechanical stability to obtain a solid fusion.
Conclusions
The advantages of this technique are lower incidence of neurologic complications, speed of execution and faster return to normal life.
Summary One case of cervical myelopathy associated to ossification of transverse atlantal ligament (OTAL) and C1 posterior arch hypoplasia in a Caucasian adult female is reported. A 53-year-old ...female affected by cervical myelopathy was treated with C1 laminectomy and posterior arthrodesis. CT scan demonstrated that the distance between ossification of the ligament and anterior cortex of the posterior arch of atlas was 6,2 mm leading to consistent space reduction for spinal cord at this level. Patient underwent spinal cord decompression and fixation with C1 poliaxial screws in lateral masses and two bilateral crossing C2 laminar screws with an improvement of neurological functions at 4-years follow-up. The association between OTAL and C1 hypoplasia was reported in very few cases. The treatment with C1 laminectomy without fusion is reported in medical literature with good clinical outcome. Our patient obtained a neurological improvement at midterm follow-up with spinal cord decompression and fusion.
The COVID-19 virus is a tremendous burden for the Italian health system. The regionally-based Italian National Health System has been reorganized. Hospitals' biggest challenge was to create new ...intensive care unit (ICU) beds, as the existing system was insufficient to meet new demand, especially in the most affected areas. Our institution in the Milan metropolitan area of Lombardy, the epicentre of the infection, was selected as one of the three regional hub for major trauma, serving a population of more than three million people. The aims were the increase the ICU beds and the rationalization of human and structural resources available for treating COVID-19 patients. In our hub hospital, the reorganization aimed to reduce the risk of infection and to obtained resources, in terms of beds and healthcare personnel to be use in the COVID-19 emergency. Non-urgent outpatient orthopaedic activity and elective surgery was also suspended. A training programme for healthcare personnel started immediately. Orthopaedic and radiological pathways dedicated to COVID-19 patients, or with possible infection, have been established. In our orthopaedic department, we passed from 70 to 26 beds. Our goal is to treat trauma surgery's patient in the “golden 72 hours” in order to reduce the overall hospital length of stay. We applied an objective priority system to manage the flow of surgical procedures in the emergency room based on clinical outcomes and guidelines. Organizing the present to face the emergency is a challenge, but in the global plan of changes in hospital management one must also think about the near future. We reported the Milan metropolitan area orthopaedic surgery management during the COVID-19 pandemic. Our decisions are not based on scientific evidence; therefore, the decision on how reorganize hospitals will likely remain in the hands of individual countries.
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