Many methods have been used, including anti- coagulation and preoperative massages of lower limbs, but without significant effects . In recent years, studies [19, 20] have pointed out that, if appropriate care can be given after fractures, it can effectively reduce incidence of deep venous thrombosis in the lower limbs and promote the recovery of patients. However, the specific nursing mode that is the most effective has not been decided. Early rehabilitation nurs- ing is a nursing mode that can be applied in many surgical operations, achieving good results [21, 22]. Therefore, the current study explored the effects of early rehabilitation care on prevention of postoperative deep venous thrombosis in patients with spinal fractures. After patients were randomly divided into two groups, the control group was given routine nursing and the experimental group was given early rehabilitation nursing based on routine nursing. In the nursing process, anticoagula- tion nursing was used. Psychological counsel- ing was also conducted for patients, developing rehabilitation plans for the mechanisms of deep venous thrombosis of lower limbs, helping patients to carry out the implementation. Postoperative pain can be alleviated through the implementation of pain care. This may improve patient cooperation and the active Table 4. Comparison of SAS scores and SDS
During the last two decades a steady increase in the annual number of patients with spinal fractures related to AS was found in Sweden. Although it has been suggested that through better medical treatment of AS the risk of suffering an unstable fracture should be reduced, this has not been found in this analysis of this registry data. The data from the SNHDR does not allow similar conclusions as a recently published study in 758 patients with AS by Vosse et al.  presenting reduced fracture risk if the patients were receiving medical therapy (OR 0.65). Swedish health- care resource utilisation in patients with AS did not differ from other developed countries with 6–7 physician visits annually, thus improved medical therapy according to international guidelines should be expected during the last decades . Thus either the effect of medical therapy has not reached epidemiological significance, yet, or other underlying factors have to be put into consideration.
If it is true that the presence or absence of trabecular bone mass reduction has an influence on the likelihood of response to treatment, it does not mean that trabecu- lar bone loss is required for a hip fracture to occur, it simply increases the risk and may influence the type of fracture that occurs. Although the definition of osteo- porosis has evolved to a risk paradigm, the notion of a t- score of −2.5 representing a significantly low BMD has to some extent survived, particularly at the spine site . Only a minority of our patients with a hip fracture had a spinal BMD t-score below this osteoporotic threshold, even fewer if there were no spinal fractures. Our sample is not random, and is in fact biased toward the spinal fracture subjects, as the presence of spinal fractures in the hip fracture population is likely less than the 50% we selected here. Nonetheless, using spinal BMD and a cut point of t-score of −2.5 only 30% of those with hip and spinal fractures and 18% of those with hip fracture with- out spinal fractures fell below that point, while 50% of those with spinal fractures alone did so. In addition we find that most women and all men in our study would not have been in the high risk category using the CAROC paradigm on the basis of femoral neck BMD alone although the CAROC graph for men is unusual in showing no age-related rise in fracture risk. We were not able to calculate prior risk on the FRAX model as we had not gathered the extra information required by that model. These observations are similar to those
Milicic et al found 16.67% of patients had deteri- orated neurologically because of late diagnosis (18). From our study, 11 patients had 3-column involve- ment. Paraplegia occurred in 2 patients before ade- quate surgical treatments were undertaken for them (cases 4 and 5). Therefore, early diagnosis and proper early management of these 3-column spinal fractures are important. Any patient with AS who seeks treat- ment for a new complaint of neck or back pain with or without neurologic deficit should be treated as if he or she has an unstable spinal fracture until proved otherwise (5, 20). Usually, spinal instability was de- termined through dynamic (flexion/extension) views or a standing lateral view of the spine, which was usually done in cases of degenerative spine disorder. Three-column injury is an extremely unstable frac- ture, and patients should be immobilized and not be moved or manipulated once the fracture is identified. The above-mentioned instability evaluation in these patients with 3-column involvement may result in severe neurologic deficits. All of our patients had anterior and middle component involvement, and most our patients had 3-component involvement. To have 3-component involvement could be from an acute onset lesion as a result of a significant trauma like our case 5, or as a result of a chronic process like our cases 6 and 12. Cardiopulmonary resuscitation, intubation, patient transfer, and improper application of traction devices to reduce a fixed flexion deformity of the cervical spine have all been implicated as causes of acute traumatic fractures of the spine, ag- gravation of previous spinal lesions, or development of new neurologic deficits in patients with AS (13).
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Introduction : Fractures of the lumbar spine and thoracolumbar junction are common in spinal trauma. The aim of this work is to analyze the nature of the indications, the morbidity as well as the results of these treatment regimens. Patients and Methods : A retrospective, single-center study, based on a re- view of 64 patients with lumbar spine and thoracolumbar junction fractures (T10-L2) without neurological disorders, was collected in the neurosurgery department of the North Hospital and University Hospital (CHU), Marseille over a period of 2 years from January 2015 to December 2016. Posterior per- cutaneous osteosynthesis were more or less associated with kyphoplasty pre- ceded anterior arthrodesis. Clinical and radiological endpoints were collected at least 6 months later. R esults: The mean follow-up was 9.5 months (6 - 24). The clinical evaluation found a mean VAS at last follow-up at 14/100 (0 - 30) and an average Oswestry score at the last follow-up at 88%. The initial average vertebral kyphosis went from 13˚ to 4˚ at the last follow-up with a correction loss of 1˚, an absolute gain of 8˚. No postoperative neurological complications were noted in our series. Conclusion : The implementation of a two-step the- rapeutic strategy with anterior reconstruction in Magerl’s lumbar spine or A3.3 thoracolumbar junction fractures allows effective and long-lasting cor- rection of lumbar lordosis and thoracic kyphosis, and obtaining a balanced How to cite this paper: Kouitcheu, R.,
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Other studies have shown an important improvement in the Oswestry Disability Index (ODI) and VAS score in patients treated with kyphoplasty for osteolytic compres- sion fractures resulting from multiple myeloma [25,26]. No leakage of cement was seen intraoperatively or in the post-operatively radiological examinations. Kyphoplasty has a lower rate of cement leakage than vertebroplasty making the cement augmentation safer [20,27,28]. A recently updated meta-analysis reported a range of leak- age after BKP (balloon kyphoplasty) up to 21.8% however a) The histopathological examination of the third patient before the radiofrequency shows a large quantity of monoclonal mye- lomatous cells (×200, H&E)
When a fracture happens in a patient with AS it should be considered as high-risk injury, especially when it is located in the cervical-thoracic junction of the spine [20,21]. The most unstable types are shearing fractures. They may have severe neurological symptoms or may lead to haemothorax or rupture of the aorta, which are serious complications [21,22]. Secondary neurological aggrava- tion may be possible due to displacement of the fractured segments, which happens mainly in hyperextension inju- ries . Furthermore, where an interval occurs between trauma and the onset of neurologic signs or worsening of the neurologic picture the formation of an epidural hematoma should be suspected and excluded by means of an MRI scan. . Diagnosis can be difficult due to pre- existing spinal alterations. The standard radiographs are inadequate to fully evaluate shearing fractures due to oste- oporosis, and the position of the shoulders (which are usually are located at a higher position). Thus, these frac- tures can be missed in the first examination and in the later stages, are characterized by vertebral corrosion, col- lapse and deformity. A misdiagnosed fracture can possibly lead to pseudarthrosis or Andersson lesion .
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In the early years of the 20th century, bone grafting in spinal surgery was popularised by Albee. Preservation and storage of canine allografts was analysed by Bauer in 1910. In the 1930s, Watson Jones introduced hyperextension casts as spinal fractures are caused by flexion violence. In 1930, for internal fixation vitallium was introduced (an alloy of chromium, molybdenum, tungsten, and cobalt). The concept of spinal cord rehabilitation was developed in 1940s by Ludwig Guttman. Reduction of spine fractures was obtained using traction and postural reduction techniques. Same year Rogers described the interspinous wiring technique. In 1945, Cloward introduced the technique of posterior lumbar interbody fusion. In 1949, Nicoll classified thoracolumbar fractures in coal miners as anterior wedge fractures, lateral wedge fractures, fracture dislocations, and neural arch fractures 11 .
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gery, and help patients establish confidence in their treatment. At the same time, the patients were provided assistance with tasks of every- day living. Fracture patients often cannot com- plete basic daily tasks by themselves because of the restricted movement; therefore, nursing staff should help them to take medicine, eat, drink water, etc., so that the patients feel taken care of. For patients worried about their prog- nosis, nurses should provide relevant knowl- edge and assurance that rehabilitation therapy will be of great help to the prognosis of the dis- ease. (2) Nursing of pressure ulcer: Patients with spinal fractures are prone to neurological damage, which leads to somatosensory dys- function and requires long-term complete bed rest, which can lead to development of pres- sure sores if the nursing is not appropriate. As the most common complication in patients with spinal fracture, pressure ulcers can be painful and reduce the quality of nursing. In this regard, the nursing staff should regularly turn patients who cannot turn on their own and also ask their family members to actively partici- pate; the nursing staff should pay close atten- tion to observe the temperature and color of the patient’s stressed skin, and provide appro- priate local massage to promote blood circula- tion; timely replace wet bedding to keep the bedding dry and clean; place softer pillows on the stressed areas to reduce local stress and friction; and instruct patients to eat high-pro- tein and high-calorie foods. For patients with pressure ulcers, 75% alcohol can be used for local application and infrared light for irradiat- ing the pressure sores; the skin should be kept dry. (3) Nursing care for urinary tract infections: Patients who have been in bed for a long time require catheterization and prolonged indwell- ing catheterization may cause urinary tract infections. Therefore, patients should be en- couraged to drink sufficient water and the pH of the urine should be closely monitored, ure- thra care should be performed twice daily, and the catheter should be replaced regularly to prevent urinary tract infection. (4) Nursing of deep vein thrombosis of the lower limbs: Long- term bed rest, combined with sensory motor dysfunction caused by neurological damage, increases the incidence of venous thrombosis. Patients should be instructed to wear elastic pants and should be encouraged to perform leg lifts and knee flexions. For patients who
Lumbar spinal fusions have been performed for spinal stability, pain relief and improved function in spinal stenosis, scoliosis, spinal fractures, infectious conditions and other lumbar spinal problems. The success of lumbar spinal fusion depends on multifactors, such as types of bone graft materials, levels and numbers of fusion, spinal instrumentation, electrical stimulation, smoking and some drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs). From January 2000 to December 2001, 88 consecutive patients, who were diagnosed with spinal stenosis or spondylolisthesis, were retrospectively enrolled in this study. One surgeon performed all 88 posterolateral spinal fusions with instrumentation and autoiliac bone graft. The patients were divided into two groups. The first group (n=30) was infused with ketorolac and fentanyl intra- venously via patient controlled analgesia (PCA) postopera- tively and the second group (n=58) was infused only with fentanyl. The spinal fusion rates and clinical outcomes of the two groups were compared. The incidence of incomplete union or nonunion was much higher in the ketorolac group, and the relative risk was approximately 6 times higher than control group (odds ratio: 5.64). The clinical outcomes, which were checked at least 1 year after surgery, showed strong correla- tions with the spinal fusion status. The control group (93.1%) showed significantly better clinical results than the ketorolac group (77.6%). Smoking had no effect on the spinal fusion outcome in this study. Even though the use of ketorolac after spinal fusion can reduce the need for morphine, thereby decreasing morphine related complications, ketorolac used via PCA at the immediate postoperative state inhibits spinal fusion resulting in a poorer clinical outcome. Therefore, NSAIDs such as ketorolac, should be avoided after posterolateral spinal fusion.
the cervical spine represent the most common level of injury in this patient population [4,7,20]. Centers with a high case load of spine trauma and a solid experience in the management of ankylosing spondylitis still have a low incidence of such injuries. Published series have usually been accumulated over a longer period of time [2,3,8,12,14,16,20,21]. A questionnaire in 1071 patients with ankylosing spondylitis revealed a 5.1% prevalence of vertebral fracture history. Up to 14% of patients with ankylosing spondylitis will experience a clinically mani- fest vertebral fracture during their lifetime . A sum- mary of published case series found cervical fractures to comprise 73% of vertebral fractures in ankylosing spond- ylitis (n = 130) . Sixty-five percent of patients with ver- tebral fractures in ankylosing spondylitis had neurological deficits . The drawing attention to these injuries is a result of the specific and uncommon fracture configura- tion with sometimes grotesque dislocations, the high rates of neurological complications and the challenging surgi- cal management. The male to female ratio is 2.5:1 in the prevalence of the disease, and the incidence of cervical spine injuries is higher in males [3,8,12,14,16,20]. One study reported a prevalence of vertebral fractures of 6.2% among males and 4.6% among females . Most studies report an average age of 60 years or slightly higher [14,21,23]. Affected patients usually have a long disease progress and a "peak" during the second or third decades after their initial diagnosis . The average disease dura- tion at the time of vertebral injuries was 24.0 ± 11.5 years after onset . Injuries are mostly localized in the lower cervical spine (C5/6 and C6/7) and in the cervico-thoracic junction, although any area of the cervical spine may be
Compared with PVP, PVP and ITR have the following advantages: 1) control the direction of the cement into the target area, 2) improve the clinical efficacy by removal of the tumor, and 3) increase the amount of PMMA injection to increase the vertebral stability and prevent compression frac- ture. Although PKP also has the advantages of minimizing cement leakage, reducing vertebral compression, relief pain and increased vertebral height, it has the risk of damaging the posterior wall when the balloon is inflated too high and can aggravate the symptoms of neurological compression in malignant vertebral compression fractures. Therefore, PVP and ITR have not only increased the application of PVP but also provided an attractive option in cases with massive PMMA leakage, destruction of the cortex of the vertebra and malignant vertebral compression fractures.
In this study, our results indicated that fracture healing was adversely affected by SCI at 4 and 8 weeks. This finding was in line with that of Garland D, which was supported the hypoth- esis that SCI impairs fracture healing . Due to low levels of physical activity, the mechanism involves denervation and disuse, which contributes to osteoclastic activity increase and enhances bone resorption. At the same time, SCI-induced vitamin D deficiency may alter calcium metabolism and increase osteoclastic activity as well . These processes may decrease bone turnover and bone mineralization and impair fracture healing. At 16 weeks, mechanical loading enhanced bone formation, because more SCI patients (9 of 15) were able to walk. Consequently, Lane-Sandhu scores were still low in the SCI group at that time point. However, this difference was not statistically significant when compared to the con- trol group. In addition, the osteoinductive potential of serum leptin showed possible activity in the SCI group and the control group at 16 weeks, which suggested that the positive effect of serum leptin on bone formation was related to the level of weight-bearing activities and normal adipose metab- olism during fracture healing. Previous studies demonstrated that low BMD bone could be caused by disturbed metab- olism of bone remodeling and led to a qualitatively reduced healing process . Here, the same result was found in both control and SCI groups: higher BMD was correlated with better fracture formation. In addition, regular weight-bearing activity and functional exercises could increase bone strength. Therefore, efforts to osteoporosis management in SCI persons will reduce the risks of lower limb fractures . Nevertheless, this investigation has several limitations, such as the small number of cases and the diversity of the patients with SCI injury. This was owing to strict adherence to the exclusion criteria. In consideration of premenopausal and postmeno- pausal factors, a comparative group of female patients was not available in our study and these would have been confounding factors on BMD and serum leptin level.
All procedures were carried out under controlled general anesthesia with endotracheal intubation in the prone position on a radiolucent operating table. Paraspinal sur- gery was performed using the S4® spinal system (Aesculap Implant Systems, Center Valley, PA, USA). Pedicle screws were implanted into the adjacent vertebrae above and below the fracture. Unilateral or bilateral pedicle screws were implanted into the fractured vertebra based on the integrity of the pedicle. Direct spinal canal decompression was performed using a dorsal lateral approach next to the erector spinae; bony fragments in the spinal canal were re- moved. Our previous studies provided basic anatomic information in Chinese for the development of this ap- proach . The erector spinae at the upper lumbar was composed of the spinalis, longissimus, and iliocostalis (Figures 1 and 2). The starting point of this paraspinal erector approach is the lateral edge of the iliocostalis.
Since data of these unusual fracture injuries in children and adolescents, their reasons and treatment is rare, we analyzed 546 patients with proven injuries under six- teen years to show, which of the spinal bod- ies is mostly affected and if in general mul- tiple injuries are more often than isolated. Another aim was to show how often the fractures needed to be operatively stabi- lized.
Abstract: BACKGROUND CONTEXT: Spinal burst fractures are a significant cause of spinal instability as well as neurological impairment. Whilst evidence suggests that the neurological trauma arises during the dynamic phase of fracture, the biomechanics underpinning the phenomenon has yet to be fully explained. Interpedicular widening (IPW) is a distinctive feature of the fracture but, despite the association with the occurrence of neurological deficit, little is known about its biomechanics.
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This is a cohort study to find the incidence of lower limb fractures among rehabilitated chronic traumatic spinal cord injured patients at or below T10 neurological level. Spinal cord injury causes significant mechano-neurochemical changes in the body, as a result of which sublesional skeletal system undergoes rapid remodeling. This leads to increased rate of bone resorption . Normal muscle tone is under the influence of central nervous system and is regulated by feedback mechanism from the stretch reflex. Specialised sensory organs such as muscle spindles act as receptors to stretch and carry afferent impulses via dorsal root to spinal cord, where it activates the alpha motor neuron to cause contraction of extrafusal muscle fibers. After SCI ,these patients present in spinal shock resulting in flaccid muscle tone which may further minimize the mechanosensation in addition to mechanical unloading which aggravate the bone loss by rapid recruitment of resorption activators(20).
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found no signs of pain, swelling, or infection at the implantation site and no major complications in the early or late postoperative periods. Yamasaki et al.  compared the effectiveness of the transplantation of bone-marrow-derived mononuclear cells (BMMNCs) plus interconnected porous calcium hydroxyapatite (IP- CHA) on early bone repair for osteonecrosis of the fem- oral head with those of without BMMNCs and found that the implantation of BMMNCs and IP-CHA appears to confer benefit in the repair of osteonecrosis and in the prevention of collapse. Sotome et al.  assessed the efficacy and safety of HAp/collagen scaffold in comparison to β-TCP and showed the porous HAp/collagen group had the highest grade of bone regeneration but also asso- ciated with higher incidence of adverse effects. The use of rhBMP-2 in the biphasic CaPs granules with or without internal fixation in patients of spondylolisthesis did not exceed grade 1 in Boden et al.’s study. However, statisti- cally greater and quicker improvement in patient-derived clinical outcome was measured in the rhBMP-2 groups . Five studies examined the use of β-TCP as a funda- mental material and composition to manage bone defects in clinical studies. One study  combined a β -TCP scaffold with MSCs and showed that the addition of MSCs resulted in more trabecular remodeling in femoral defects. Ollivier et al.  showed that the addition of rhBMP-7 to a TCP scaffold is safe and efficient in the treatment of re- calcitrant bone union. Three studies [44–46] in clinical studies examined the use of BoneSave, a porous bone graft substitute made of β-TCP and HAp ceramic. Kapur et al.  showed that 56.7% of cases achieved successful fusion in 45 posterolateral inter-transverse spinal patients. Two of studies involved impaction grafting of BoneSave and allograft, which is an effective method of dealing with loss of the acetabulum in short- and medium-term studies [45, 46]. A novel study about bonelike scaffold was studied . The result indicated that bonelike can be an excellent bioactive scaffold and therefore regeneration of the defects was achieved in a rapid, controlled manner.
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Reductions in bone density are a major determinant of vertebral fractures in the elderly population. However, women have a greater incidence of fractures than men, although their spinal bone densities are comparable. Recent observations indicate that women have 20- 25% smaller vertebrae than men after accounting for differences in body size. To assess whether elderly women with vertebral fractures have smaller vertebrae than women who do not experience fractures, we reviewed 1,061 computed tomography bone density studies and gathered 32-matched pairs of elderly women, with reduced bone density, whose main difference was absence or presence of vertebral fractures. Detailed measurements of the dimensions of unfractured vertebrae and the moment arm of spinal musculature from T12 to L4 were calculated from computed tomography images in the 32 pairs of women matched for race, age, height, weight, and bone density. The cross-sectional area of unfractured vertebrae was 4.9-11.5% (10.5 +/- 1.4 vs 9.7 +/- 1.5 cm2; P < 0.0001) smaller and the moment arm of spinal musculature was 3.2-7.4% (56.4 +/- 5.1 vs 53.1 +/- 4.4 mm; P < 0.0001) shorter in women with fractures, implying that mechanical stress within intact vertebral bodies for equivalent loads is 5-17% greater in women with fractures compared to women without fractures. Such significant variations are very likely to contribute to vertebral fractures in osteoporotic women.
therefore it simulates a peripheral-nerve injury unlike in injuries to the spinal cord or the conus medullaris.(2,6,14,15) .These features explain why severe neurological deficits are infrequent in this region and that the neurological resolution is likely it is present. The body's center of gravity in the lumbar spine falls posterior to the axis of the vertebral column or along it. The apex from the lordotic curve of the lumbar spine falls on L3 and the lordosis is decreased by small amount of flexion which places the axially directed load force-of-injury vector directly through body of the vertebra.(14) This reduces the flexion moment arm to the mid lumbar region and hence the chance of kyphosis and collapse is reduced. (14) In The lumbar region pure axial load injuries are more common. (15) The risk of worsening of neurological status is low because the posterior column and with its elements provide stability.(14–16) The presence of iliolumbar ligaments and the fact that it is located distal to pelvic brim help stabilize the fractures of the lower lumbar region when compared with fractures at the thoracolumbar junction(8). This is a unique feature. Therefore the treatment of mid lumbar fractures can‟t be optimized from the literature focusing on thoracolumbar fractures. Mid Lumbar fractures represent a separate entity and they are more stable after a vertebral column injury because of sagittal contour, neurologic elements, and the iliolumbar ligaments.(8,16,17)
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