High-Grade Lumbar Spondylolisthesis.

Most high-grade spondylolistheses are resultant from isthmic spondylolisthesis, as complete discontinuity of the pars is typically necessary to allow for this degree of anterior vertebral translation, although can occur less commonly in other scenarios. Higher-grade slips can affect the global sagittal balance of the patient and often result in altered gait patterns and compensatory posturing. Management usually entails surgical decompression and fusion with instrumentation. The addition of anterior column support carries many advantages, including greater surface area for fusion, dynamic compression load sharing at the lumbosacral junction, and a powerful adjunct for deformity correction.

Predicting survival in older patients treated for cervical spine fractures: development of a clinical survival score.

BACKGROUND CONTEXT: Emerging literature has identified the importance of pretreatment health and functional status as influential in the prognostication of survival. A comprehensive, accessible, predictive model for survival following cervical spine fracture has yet to be developed. PURPOSE: To develop an accessible and intuitive predictive model for survival in individuals aged 50 and older treated for cervical spine fractures. STUDY DESIGN: Retrospective review of records from two tertiary care centers (2009-2016). PATIENT SAMPLE: Patients age 50 and older who received operative or nonoperative management for cervical fractures. OUTCOME MEASURES: One-year mortality was the primary outcome with 3-month and 2-year mortality considered secondarily. METHODS: Multivariable logistic regression was used to identify factors independently associated with mortality. The magnitude and precision of the relationship with 1-year mortality for statistically significant variables determined weighting in the scoring system subsequently developed. Score performance was tested through multivariable regression and bootstrap simulation. In a sensitivity test, the performance of the score developed for 1-year mortality was assessed using figures for the 3-month and 2-year time-points. RESULTS: We included 1,758 patients. Mortality rates were 12% at 3 months, 17% at 1 year, and 21% at 2 years. Following multivariable testing age, injury severity score and Glasgow coma scale demonstrated the strongest predictive values for a base score, followed by serum albumin and ambulatory status. The resultant composite score ranged from 0 (base score≤4, albumin≤3.5 g/dL, and dependent/nonambulator at presentation) to a maximum of 4 (base score≥5, albumin>3.5 g/dL, and independent ambulator at presentation). Following multivariable analysis, when compared to patients with a score of 4, significantly increased odds of 1-year mortality were appreciated for those with scores of 3 (odds ratio [OR] 7.35; 95% confidence interval [CI] 3.77, 14.32), 2 (OR 8.43; 95% CI 4.66, 15.25), 1 (OR 17.47; 95% CI 9.81, 31.11), and 0 (OR 26.58; 95% CI 13.87, 50.92). Score performance was unchanged in bootstrap testing and sensitivity analyses. CONCLUSIONS: We have developed a useful prognostic utility capable of informing survival in individuals age 50 and older, following cervical spine fractures. The score can be applied to adjust patient expectations, anticipate outcomes, and as an adjunct to decision-making in the postinjury period.

Evaluating the Cervical Spine in the Blunt Trauma Patient.

Following a blunt trauma, the goal of the cervical spine evaluation is to identify any injuries that might require active management: either through continued use of a collar or surgical stabilization. This is achieved through a step-wise approach that considers the nature of the patient's trauma, presenting complaints, distracting injuries and capacity to cooperate with the examination. In the last 15 to 20 years, technological advances in radiographic imaging have improved clinicians' abilities to certify the cervical spine as free of injury following blunt trauma. Within the last decade, the use of CT has supplanted plain radiograph imaging as the standard screening modality. Although MRI is more sensitive than CT in identifying occult cervical injury, particularly ligamentous or soft-tissue trauma, the standard addition of MRI to CT evaluation alone does not significantly increase the detection of clinically important cervical injuries.