Early venous thromboembolism prophylaxis with enoxaparin in patients with blunt traumatic brain injury.

OBJECTIVE: To determine the safety of early enoxaparin for venous thromboembolism (VTE) prophylaxis in patients with blunt traumatic brain injury (TBI). METHODS: Prospective observational study of patients with TBI who received enoxaparin within 48 hours after admission. Brain computed tomography (CT) scans were obtained at the time of admission, at 24 hours, and at variable intervals thereafter based on clinical course. Patients were excluded from the study for intracerebral contusions >/=2 cm, multiple contusions within one brain region, subdural or epidural hematomas >/=8 mm, increased size or number of lesions on follow-up CT, persistent intracranial pressure >20 mm Hg, or neurosurgeon or trauma surgeon reluctance to initiate early pharmacologic VTE prophylaxis. Bleeding complications were defined as CT progression of hemorrhage by Marshall CT Classification or radiologists' report, regardless of any neurologic deterioration. Main outcomes measured were intracranial bleeding complications, discharge Glasgow Outcome Score, and hospital mortality. RESULTS: Five hundred twenty-five patients were studied. Eighteen patients (3.4%) had progressive hemorrhagic CT changes after receiving enoxaparin, 12 of whom had no change in treatment, neurologic status, or outcome. Six patients (1.1%) had a change in treatment or potential outcome, including three who required subsequent craniotomy. Twenty-one patients (4.0%) died, and pharmacologic prophylaxis may have contributed to one death (0.2%). Discharge Glasgow Outcome Scores were 445 (84.8%) good recovery, 19 (3.6%) moderate disability, 36 (6.8%) severe disability, 4 (0.8%) persistent vegetative state, and 21 (4.0%) dead. CONCLUSION: Enoxaparin should be considered as an option for early VTE prophylaxis in selected patients with blunt TBI. Early enoxaparin should be strongly considered in those patients with TBI with additional high risk traumatic injuries.

Kyphoplasty treatment of vertebral fractures: 2-year outcomes show sustained benefits.

STUDY DESIGN: Retrospective single-center consecutive case series with two [corrected] year follow-up. OBJECTIVES: To examine kyphoplasty [corrected] patients for long-lasting clinical and radiological outcomes [corrected] including effects on [corrected] vertebral body shape. SUMMARY OF BACKGROUND DATA: Kyphoplasty is the minimally-invasive [corrected] reduction and stabilization of vertebral body fractures [corrected] resulting in pain relief and improved physical function as described in our previously published one-year outcomes report [corrected] METHODS: Safety (complications and cement extravasation) was monitored in all 117 patients (151 fractures) treated through December 2001. Preoperative and postoperative VAS [corrected] pain scores, analgesia usage, and ambulatory status were compared in 77 [corrected] of these patients with at least two-year [corrected] follow-up. Anterior, midline, posterior vertebral body heights, and height ratios from this cohort were assessed pre-operatively, [corrected] immediately postoperative [corrected] and after 2 years of follow-up. RESULTS: Pain scores, patient ability to ambulate independently and without difficulty, and need for prescription pain medications improved significantly (P < 0.001) after kyphoplasty [corrected] and remained unchanged or improved at 2 years [corrected] Vertebral heights significantly (P < 0.001) [corrected] increased at all postoperative intervals, with > or = 10% height increases in 84% [corrected] of fractures. Morphometric height ratios for treated fractures also significantly increased (P < 0.001): 0.67 +/- 0.24 to 0.81 +/- 0.21 and 0.64 +/- 0.24 [corrected] to 0.83 +/- 0.11. Asymptomatic cement extravasation occurred in 11.3% of fractures, and during the follow-up period [corrected] additional fractures occurred in previously untreated levels at a rate of 4.5% per year. There were no kyphoplasty-related [corrected] complications. CONCLUSIONS: Kyphoplasty markedly improves clinical outcome [corrected] and results in significant vertebral height restoration and normalization of morphologic shape indices [corrected] that remain stable for at least two [corrected] years following treatment.

Open vertebral cement augmentation combined with lumbar decompression for the operative management of thoracolumbar stenosis secondary to osteoporotic burst fractures.

Osteoporotic burst fractures with neurologic symptoms are typically treated with neural decompression and multilevel instrumented fusion. These large surgical interventions are challenging because of patients' advanced ages, medical co-morbidities, and poor fixation secondary to osteoporosis. The purpose of this retrospective clinical study was to describe a novel technique for the treatment of osteoporotic burst fractures and symptomatic spinal stenosis via a limited thoracolumbar decompression with open cement augmentation [vertebroplasty (VP) or kyphoplasty (KP)]. Indications for decompression and cement augmentation were intractable pain at the level of a known osteoporotic burst fracture with symptoms of spinal stenosis. As such, 25 patients (mean age, 76.1 years) with low-energy, osteoporotic, thoracolumbar burst fractures (7 males, 18 females; 39 fractures) were included. In all cases, laminectomy of the stenotic level(s) was followed by vertebral cement augmentation (9 VP; 16 KP). When a spondylolisthesis at the decompressed level was present, instrumentation was applied across the listhetic level (n = 9). Clinical outcome (1 = poor to 4 = excellent) was assessed on last clinical follow-up (mean, 44.8 wks). In addition, a modified MacNab's grading criteria was used to objectively assess patient outcomes postoperatively. Radiographic analysis of sagittal contour was assessed preoperatively, immediately postoperatively, and at final follow-up. The average time from onset of symptoms to intervention was 19 weeks (range, 0.3-94 wks). A mean of 1.6 fractures/patient was augmented (range, 1-3 fractures) and 2.8 levels were decompressed (range, 1-6 levels). No statistical difference in anatomic distribution or number of fractures between the VP and KP groups or in the instrumented versus noninstrumented patients was noted (P > 0.05). An overall subjective outcome score of 3.4 was noted. Twenty of 25 patients were graded as excellent/good according to the modified MacNab's criteria. The choice of augmentation procedure or use of instrumentation did not predict outcome (P = 0.08). Overall, 1.7 degrees of sagittal correction was obtained at final follow-up. One patient was noted to have progressive kyphosis after KP. The use of a limited-posterior decompression and open cement augmentation via VP or KP is a safe treatment option for patients who have osteoporotic burst fractures and who are incapacitated from fracture pain and concomitant stenosis. After thoracolumbar decompression, open VP/KP provides direct visualization of the posterior vertebral body wall, allowing for safe cement augmentation of burst fractures, stabilizing the spine, and obviating the need for extensive spinal reconstruction. Although clinically successful, this technique warrants careful patient selection.

Decreases in the number and severity of morphometrically defined vertebral deformities after kyphoplasty.

OBJECT: Vertebral body (VB) deformities have been associated with increased patient morbidity and mortality rates. The aim of this retrospective, consecutive single-center cohort study was to determine the effectiveness of kyphoplasty in reducing morphometrically defined VB deformity, including deformity shape types (wedge, biconcave, or crush) and grade (severity). METHODS: The authors identified 100 patients (70% women; mean age 76.1 years) in whom 138 vertebral fractures (T-4 through L-5; mean fracture age 2.7 months) that were treated between May 2000 and December 2001 were radiographically evaluated preoperatively and at the last follow-up visit (mean follow-up duration 16.9 months). Fractures were divided into four groups by level: T5-9 (28 fractures), T10-12 (41), L1-2 (42), and L3-5 (27). Anterior, midline, posterior, and predicted posterior vertebral heights for fractured and adjacent unfractured reference vertebrae were measured on lateral radiographs. The deformity type and grade were mathematically defined using the modified methods of McCloskey-Kanis and Black. The total number of deformities decreased from 89.9 to 53.6% after kyphoplasty (p < 0.0001). The number of fractures with wedge, biconcave, or crush deformity decreased 22.5, 59.1, and 67.7% (p = 0.0699, p = 0.0222, p = 0.0007), respectively. The number of the more severe Grade 2 deformities decreased (79.7 to 37.0%; p < 0.0001). Kyphoplasty effectively decreased the number of deformed fractures in all vertebral level groups (T5-9, p = 0.0023; T10-12, p = 0.0105; L1-2, p < 0.0001; L3-5, p = 0.0028). CONCLUSIONS: Kyphoplasty resulted in significant normalization of vertebral shapes in patients with symptomatic vertebral fractures, reducing the number and severity of deformed fractures postoperatively.

Balloon kyphoplasty: one-year outcomes in vertebral body height restoration, chronic pain, and activity levels.

OBJECT: The authors assessed the safety of balloon kyphoplasty in the reduction and repair of osteopenic vertebral compression fractures and report functional outcomes (back pain and activity levels) in the first 96 patients (with 133 fractures) at their institution. Additionally they provide radiographic outcomes in the first 26 patients (41 fractures) treated and followed for 1 year. METHODS: The authors conducted a retrospective chart review of functional outcomes and evaluated radiographs obtained at 1 week, 1 month, 3 months, 6 months, and 1 year postoperatively. CONCLUSIONS: Balloon kyphoplasty safely increases vertebral body height, decreases chronic back pain, and quickly returns geriatric patients to higher activity levels, leading to increased independence and quality of life.