Minimally invasive surgery technique for unstable pelvic ring fractures with severe vertical shear displacement: A retrospective study.

BACKGROUND: Unstable pelvic fractures, especially vertical shear fractures, require surgery for correct reduction, rigid fixation, and improved postoperative outcomes. Herein, we assess the effectiveness of our minimally invasive procedure for the management of unstable pelvic fractures. HYPOTHESIS: We hypothesized that this procedure would be useful for the management of unstable pelvic fractures. PATIENTS AND METHODS: This study included 28 patients with unstable pelvic fractures (vertical shear injuries; AO types C1-3) treated using minimally invasive surgery for spinopelvic fixation (MIS-SP) between 2014 and 2020 (mean follow-up time, 15 months). The MIS-SP requires four percutaneous pedicle screws and four iliac screw insertions. Subsequently, reduction and fixation are performed. RESULTS: The mean preoperative displacement of the posterior pelvic elements in craniocaudal correction was 17.6 (range, 9.0-32.2) mm. The mean length of the craniocaudal reduction was 16.5 (8.1-30.1) mm, with a mean reduction rate of 93.5% (78%-100%). The mean length of the mediolateral reduction was 11.3 (3.9-19.6) mm, with a mean reduction rate of 87.3% (76%-100%). DISCUSSION: Our novel reduction and fixation procedure is a powerful, minimally invasive option for the treatment of unstable pelvic ring fractures. LEVEL OF EVIDENCE: III.

Retro-odontoid pseudotumor with uncommon presentation of cervical spine injury.

BACKGROUND: We report the first case of retro-odontoid pseudotumor with an isolated symptom of C2-C3 dysesthesia triggered by a traumatic event. CASE PRESENTATION: An 86-year-old man, who was a wood craftsman for more than 50 years, presented to the emergency room with sudden-onset severe posterior head and neck dysesthesia after accidentally falling backward. No neurological impairment of the extremities was noted. Computed tomography revealed a C2-C7 osteophyte formation, mainly in front of the vertebral bodies. Moreover, magnetic resonance imaging showed cervical spinal cord compression by a soft tissue mass posterior to the odontoid process of the axis. Therefore, we diagnosed a cervical spine injury with an isolated symptom of C2-C3 dysesthesia due to a retro-odontoid pseudotumor. He did not undergo surgical intervention and was transferred to a rehabilitation hospital on day 11 for pain control. CONCLUSION: Our report could be useful to emergency physicians dealing with similar cases of cervical symptoms following trauma.

Retrospective high volume comparative study suggests that patients on aspirin could have immediate surgery for hip fractures without significant blood loss.

PURPOSE: This study aimed to investigate the effects of aspirin on peri-operative hidden blood loss during hip fracture surgery by adjusting for possible factors affecting blood loss using a propensity score matching method. METHODS: We retrospectively collected data from a cohort of isolated hip fracture patients (aged ≥ 65 years)who underwent surgery from January 2010 to December 2019. The study's primary outcome was blood loss from admission to the day after surgery in the aspirin and control groups. We estimated the hidden blood loss, calculated based on patient's blood volume, haemoglobin measurements, and blood transfusions. The secondary outcome focused on the requirement for blood transfusion. We adjusted for possible factors affecting blood loss using a propensity score matching method and statistically examined the effects of aspirin on hip fracture surgery. RESULTS: We enrolled 806 patients of whom 271 (34%) were taking anticoagulant and antiplatelet drugs, while 114 (14%) were taking only aspirin (aspirin group). A total of 535 patients were not taking antiplatelets and anticoagulants (control group). In propensity score matching, 103 patients were matched. Aspirin was not associated with a significantly higher risk of hidden blood loss (aspirin group; median 598 mL [410-783 mL] vs control group; median 556 ml [321-741 mL], p = 0.14) and higher risk of blood transfusion requirement (aspirin group; 49 patients [48%] vs control group; 39 patients [38%], p = 0.21). CONCLUSION: Aspirin did not affect peri-operative blood loss in hip fracture surgery. We concluded that patients taking aspirin can safely undergo hip fracture surgery without delay.

Minimally Invasive Surgery for Unstable Pelvic Ring Fractures: Transiliac Rod and Screw Fixation.

Pelvic fractures occur with high-energy trauma, and the patient's clinical status is unstable. Although a number of surgical methods for unstable pelvic fractures are available, none can achieve strong fixation with minimal invasiveness. We describe a surgical transiliac rod and screw fixation (TIF) procedure that provides minimally invasive fixation using a spinal implant for unstable pelvic ring fractures, and we retrospectively analyzed the procedure's outcomes in 27 patients with type B or C1 fractures (based on the AO/ATO classification system). Small skin incisions are made above the posterior superior iliac spines on both sides. The ilium is partially resected, and two iliac screws are inserted on each side. The spinous process of the sacral spine is then shaved, and the iliac screws are connected to 2 rods, one placed caudal to the other. Corrective manipulation is performed at the fracture site, and the rods are connected with connectors. Favorable fracture reduction, defined as a rating of 'excellent' or 'good,' was achieved in 77.8% of the patients. Transiliac rod and screw fixation (TIF) will be a useful therapeutic option for unstable pelvic ring fractures.

Insufficiency and deficiency of vitamin D in elderly patients with fragility fractures of the hip in the Japanese population.

BACKGROUND: Data of vitamin D sufficiency in Asian patients with osteoporotic fragility hip fractures are limited. This study aimed to obtain data from the Japanese population. METHODS: Patients aged 60 years or older with hip fractures were prospectively enrolled. Serum 25-hydroxyvitamin D (25(OH)D) levels were measured. Levels were compared between patients receiving and not receiving treatment for osteoporosis, those with and without previous contralateral hip fractures, and those with femoral neck versus trochanteric fractures. Sex-based differences were also assessed. The serum levels in patients younger than 60 years with extremity fractures were assessed, and differences between elderly and younger patients were evaluated. The individual correlation between 25(OH)D levels and the ultraviolet (UV) index and age was analyzed in elderly patients with hip fractures. RESULTS: The data of 360 patients (aged 84.7 ± 8.2 years), comprising 80 men and 280 women, were analyzed. The mean 25(OH)D level was 16.5 ± 7.2 ng/mL. The prevalence of vitamin D insufficiency (25(OH)D <30 ng/mL) and deficiency (25(OH)D <20 ng/mL) was 93.9% and 71.7%, respectively. A significant difference was noted in the prevalence of vitamin D deficiency between patients with and without previous contralateral hip fractures. Age and 25(OH)D levels were found to be correlated, with no correlation between the UV index and the 25(OH)D levels. The 25(OH)D level in the younger population (n = 123) was 20.7 ± 8.6 ng/mL, which was significantly higher than that of the elderly. CONCLUSION: Perennial vitamin D insufficiency is prevalent in elderly Japanese patients with hip fractures.

Risk factors for lumbosacral plexus palsy related to pelvic fracture.

STUDY DESIGN: A retrospective study. OBJECTIVE: We assessed risk factors for lumbosacral plexus palsy related to pelvic fracture that can be evaluated during the acute injury phase with diagnostics such as computed tomography (CT). SUMMARY OF BACKGROUND DATA: Many patients with pelvic fracture are in vital shock, with polytrauma and loss of consciousness, making an accurate neurologic examination very difficult in the emergency room. METHODS: This study included 22 patients who had AO classification type B or C pelvic fractures. The 22 patients had 27 posterior osteoligamentary lesions. The average injury severity score (ISS) was 27.5 (range, 16-50). Age, sex, ISS, suicidal jump, longitudinal displacement, sacral transverse fracture, pubic fracture, lumbar transverse process fracture, type of pelvic fracture (AO), and type of sacral fracture (Denis) were examined for a correlation with the lumbosacral plexus palsy. Using coronal reconstruction CT, we considered a 10 mm or greater displacement at the sacrum or sacroiliac joint to be a longitudinal displacement. Transverse sacral fracture was diagnosed by sagittal reconstruction CT. RESULTS: Of the 22 patients, 5 (22.7%) had lumbosacral plexus palsy (8 of 27 pelvic fractures) detected during treatment. The incidence of lumbosacral plexus palsy was not related to age, sex, ISS. Incidence of palsy was significantly higher when the patient's affected side had longitudinal displacement. Patients who had made a suicidal jump or had a sacral transverse fracture also had a significantly higher risk for lumbosacral plexus palsy. Palsy was not related to the type of pelvic fracture (AO) or sacral fracture (Denis). CONCLUSION: In this study, longitudinal displacement of the pelvis, transverse sacral fracture, and trauma from a suicidal jump were risk factors for lumbosacral plexus palsy. These risk factors were helpful in our examination of patients who had severe pelvic fracture with loss of consciousness.

Cervical cord injury in patients with ankylosed spines: progressive paraplegia in two patients after posterior fusion without decompression.

STUDY DESIGN: Case report and clinical discussion. OBJECTIVE: To describe technical pitfall to treat 2 cervical cord injuries, including dislocations in patients with ankylosed spine due to diffuse idiopathic skeletal hyperostosis (DISH) or ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA: DISH and OPLL are disease processes similar in pathology, which can lead to unexpected fractures due to low-energy trauma. In reported cases of fracture of the ankylosed spine in patients with DISH or OPLL, increasing lever arm and a grossly unstable fracture occurred. However, the actual surgical intervention for these fractures and spinal cord injuries was not discussed. METHODS: We report 2 cervical cord injuries, including dislocations in patients with ankylosed spine due to DISH or OPLL. RESULTS: Two patients underwent posterior fusion without decompression; however, postoperative progressive paraplegia still occurred. There were 3 points in common: these patients had ankylosed spines due to DISH or OPLL; they were elderly and had spinal canal stenosis; and after undergoing posterior fusion without decompression, their bilateral, lower extremity palsies worsened after surgery. Cervical alignment was slightly different after posterior fusion, and this change concentrated in one segment because adjacent vertebral bodies were ankylosed, and thus, immoveable. Additionally, this stress caused infolding of the ligamentum flavum with resultant spinal cord compression. CONCLUSION: In these cases, we recommend posterior fusion and decompression such as laminoplasty to avoid worsening palsy.

Deep venous thrombosis in patients with acute cervical spinal cord injury in a Japanese population: assessment with Doppler ultrasonography.

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary thromboembolism are major complications in patients with acute spinal cord injury. The incidence of DVT in patients with a spinal cord injury has ranged from 5% to 26% in several countries; however, the incidence in Japan is unknown. METHODS: We retrospectively assessed 52 patients with acute cervical spinal cord injury. According to the American Spinal Injury Association Impairment Scale (AIS) at admission, 17 patients were grade A, 15 grade B, 17 grade C, and 3 grade D. These patients were assessed for a DVT using color Doppler ultrasonography (US) regardless of whether they were symptomatic. As standard protocol, we perform Doppler US 5 days after injury; however, this retrospective research included patients who were assessed 2-13 days after injury. RESULTS: In this study, 11 of 52 (21%) patients had DVT. Three patients had DVT of the right leg, six of the left leg, and two of bilateral legs. There were two proximal-type DVTs and nine distal-type DVTs. No patients had a symptomatic thrombopulmonary embolism. In all, 10 of 41 (24%) men had DVT and 1 of 11 (9%) women had DVT (P = 0.26). A total of 7 of 32 (22%) patients who had complete motor palsy (AIS A or B) had DVT, and 4 of 20 (20%) with incomplete motor palsy (AIS C or D) had DVT (P = 0.58). DVT was found 2-13 days after injury. CONCLUSIONS: In this study of the Japanese population, 11 of 52 (21%) patients with acute cervical spinal cord injury had DVT. Several studies showed there were no differences in the incidence of DVT between patients with complete or incomplete palsy, and our study showed the same results. Many asymptomatic patients had DVT, so asymptomatic patients should not be neglected.

Clinical accuracy of 3D fluoroscopy-assisted cervical pedicle screw insertion.

OBJECT: Cervical pedicle screw (PS) misplacement leads to injury of the spinal cord, nerve root, and vertebral artery. Recently, several investigators reported on the usefulness of a spinal navigation system that improves the accuracy of PS insertion. In this study, the authors assessed the accuracy of cervical pedicle, lateral mass, and odontoid screw insertions placed using a 3D fluoroscopy navigation system, the Iso-C3D unit. METHODS: In this prospective analysis of the authors' initial 50 cases of 3D fluoroscopy-assisted cervical screw insertion, the authors inserted 176 PSs, 58 lateral mass screws, and 5 odontoid screws into the C1-7 vertebrae. They placed screws using intraoperative acquisition of data by the isocentric C-arm fluoroscope and a computer navigation system. They obtained postoperative fine-cut CT scans in all patients and assessed the accuracy of screw insertion. RESULTS: A PS (>or= 3.5 mm) could be inserted into 24 (63%) of 38 pedicles at the level of C-3, 18 (53%) of 34 pedicles at C-4, 30 (65%) of 46 at C-5, 33 (80%) of 41 at C-6, and 43 (100%) of 43 at C-7. Of 176 PSs inserted into vertebrae between C-2 and C-7, 171 screws (97.2%) were classified as Grade 1 (no pedicle perforation), and 5 screws (2.8%) were classified as Grade 2 (screw perforation of the cortex by up to 2 mm). Clinically significant screw deviation in the present study was considered Grade 3 (screw perforation of the cortex by > 2 mm), and this occurred in 0% of the placements. CONCLUSIONS: In this study, the authors were able to correctly insert cervical PSs using the 3D fluoroscopy and navigation system.