Cervical spine trauma is a common problem with a wide range of severity from minor ligamentous injury to frank osteo-ligamentous instability with spinal cord injury. The emergent evaluation of patients at risk relies on standardized clinical and radiographic protocols to identify injuries; elucidate associated pathology; classify injuries; and predict instability, treatment and outcomes. The unique anatomy of each region of the cervical spine demands a review of each segment individually. This article examines both upper cervical spine injuries, as well as subaxial spine trauma. The purpose of this article is to provide a review of the broad topic of cervical spine trauma with reference to the classic literature, as well as to summarize all recently available literature on each topic. Identification of References for Inclusion: A Pubmed and Ovid search was performed for each topic in the review to identify recently published articles relevant to the review. In addition prior reviews and classic references were evaluated individually for inclusion of classic papers, classifications and previously unidentified references.

The most common site of injury to the spine is the thoracolumbar junction which is the mechanical transition junction between the rigid thoracic and the more flexible lumbar spine. The lumbar spine is another site which is more prone to injury. Absence of stabilizing articulations with the ribs, lordotic posture and more sagitally oriented facet joints are the most obvious explanations. Burst fractures of the spine account for 14% of all spinal injuries. Though common, thoracolumbar and lumbar burst fractures present a number of important treatment challenges. There has been substantial controversy related to the indications for nonoperative or operative management of these fractures. Disagreement also exists regarding the choice of the surgical approach. A large number of thoracolumbar and lumbar fractures can be treated conservatively while some fractures require surgery. Selecting an appropriate surgical option requires an in-depth understanding of the different methods of decompression, stabilization and/or fusion. Anterior surgery has the advantage of the greatest degree of canal decompression and offers the benefit of limiting the number of motion segments fused. These advantages come at the added cost of increased time for the surgery and the related morbidity of the surgical approach. Posterior surgery enjoys the advantage of being more familiar to the operating surgeons and can be an effective approach. However, the limitations of this approach include inadequate decompression, recurrence of the deformity and implant failure. Though many of the principles are the same, the treatment of low lumbar burst fractures requires some additional consideration due to the difficulty of approaching this region anteriorly. Avoiding complications of these surgeries are another important aspect and can be achieved by following an algorithmic approach to patient assessment, proper radiological examination and precision in decision-making regarding management. A detailed understanding of the mechanism of injury and their unique biomechanical propensities following various forms of treatment can help the spinal surgeon manage such patients effectively and prevent devastating complications.

Attempts of treating unstable fractures of the thoracolumbar junction by posterior reduction and fixation alone often result in a significant loss of correction, especially in lesions where a severe destruction of the vertebral body and the intervertebral disc is present. The conventional open approaches like classic thoraco-phreno-lumbotomy produces additional iatrogenic trauma at the lateral chest and abdominal wall which not rarely leads to intercostal neuralgia, as well as post-thoracotomy syndromes. The endoscopic trans-diaphragmatic approach described below opens up the whole thoracolumbar junction to a minimally invasive procedure allowing one to perform all the procedures needed for a full reconstruction of the anterior column of the spine like corpectomy, decompression, vertebral body replacement and anterior plating. The key to address also the subdiaphragmal and retroperitoneal section of the thoracolumbar junction is a partial detachment of the diaphragm which runs along the attachment at the spine and the ribs. The technique was published first in 1998 and has been used now in 650 endoscopic procedures at the thoracolumbar junction out of a total of more than 1300 thoracoscopic operations of the spine in the BG Unfallklinik Murnau, Germany since 1996.

Background: A clinico-epidemiological study helps to plan future preventive measures and management strategies for spinal trauma. This is a 10 years' retrospective review of spinal-injury patients treated at a tertiary health center in the eastern of Nepal to determine clinico-epidemiological aspects of spinal-injury patients in a predominantly rural population of eastern Nepal. Materials and Methods : All medical record files of patients with spinal injury from 1996 to 2005 in the Medical Record Section of BPKIHS (B. P. Koirala Institute of Health Sciences) were studied. The preformed pro forma consisting age, sex, place of living, mode of injury, hospital stay level of injury, site of injury, associated injury, Frankel grading of neural deficit and treatment modality was filled from the record files of patients. These parameters were entered in Excel 8 and analyzed by EPI INFO 2002. Details of 896 patients of spinal injury were recorded in the 10-year period of review. Results : 684 (76.35%) male and 212 (23.66%) female patients with mean age of 41.74 ± 16.53 years and 38.56 ± 15.86 years respectively were studied. Two hundred forty-two (27%) patients were from hilly districts of eastern Nepal. Fall from height [in 350 (39%) patients] was the commonest mode of spinal injury. Six hundred thirty-six (71%) patients presented with a neurological deficit. Seven hundred thirty-three (85%) patients were treated conservatively, compared to 163 (15%) surgically treated patients. One hundred forty-six (22%) patients were treated with operative interventions in the last five years. Conclusion : The study shows that the most vulnerable group for spine injury was the group of patients of productive age with late presentation (i.e., injury hospital duration - 41.64 ± 54.24 hours) without proper prehospital management. The treatment modalities have changed (from conservative to surgical) in this part of the world. These specific observations help us in further planning for preventive measures and management in our setting.

Background : The epidemiological data of a given population on spinal trauma in India is lacking. The present study was undertaken to evaluate the profile of patients with thoracolumbar fractures in a tertiary care hospital in an urban setup. Materials and Methods : Four hundred forty patients with thoracolumbar spinal injuries admitted from January 1990 to May 2000 to the All India Institute of Medical Sciences were included in the analysis. Both retrospective data retrieval and prospective data evaluation of patients were done from January 1998 to May 2000. Epidemiological factors like age, sex and type of injury, mode of transport, time of reporting and number of transfers before admission were recorded. Frankel's grading was used to assess neurological status. Functional assessment of all patients was done using the FIM™ instrument (Functional Independence Measure). Average followup was 33 months (24-41 months). Results : Of the 440 patients, females comprised 17.95% (n=79), while 82.04% (n=361) were males. As many as 40.9% (n=180) of them were in the third decade. Fall from height remained the most common cause (n=230, 52.3%). Two hundred sixty (59.1%) patients reported within 48 hours. Thirty-two (7.27%) patients had single transfer, and all 32 showed complete independence for mobility at final followup. 100 of 260 (38.5%) patients reporting within 48 hours developed pressure sores, while 114 of 142 (80.28%) patients reporting after 5 days developed pressure sores. Conclusion : The present study highlights the magnitude of the problems of our trauma-care and transport system and the difference an effective system can make in the care of spinal injury patients. There is an urgent need for epidemiological data on a larger scale to emphasize the need for a better trauma-care system and pave way for adaptation of well-established trauma-care systems from developed countries.

Background: The spinal cord injured patients if congregated early in spinal units where better facilities and dedicated expert care exist the outcome of treatment and rehabilitation, can be improved. The objective of this study is to find out the various factors responsible for a delay in the presentation of spinal injury patients to the specialized spinal trauma units and to suggest steps to improve the quality of care of the spinal trauma patients in the Indian setup. Materials and Methods: Sixty patients of traumatic spinal cord injury admitted for rehabilitation between August 2005 and May 2006 were enrolled into the study and their data was analyzed. Results: Eighty-five per cent of the spinal cord injured patients were males and the mean age was 34 years (range 13-56 years). Twenty-nine (48.33%) of the spinal injuries occurred due to fall from height. There was an average of 45 days (range 0-188 days) of delay in presentation to a specialized spinal unit and most of the time the cause for the delay was unawareness on the part of patients and/or doctors regarding specialized spinal units. In 38 (62.5%) cases the mode of transportation of the spinal cord injured patient to the first visited hospital was by their own conveyance and the attendants of the patients did not have any idea about precautions essential to prevent neurological deterioration. Seventeen (28.33%) patients were given injection solumedrol with conservative treatment, 35 (60%) patients were given only conservative treatment and seven patients were operated (11.66%) upon at initially visited hospital. Of the seven patients operated five were fixed with posterior Harrington instrumentation (71.42%) and two (28.57%) were operated by short segment posterior pedicle screw fixation. None of the patients were subjected to physiotherapy-assisted transfers or wheel chair skills or even basic postural training, proper bladder/ bowel training program and sitting balance. Conclusion: Awareness on the part of the general population, attendants of the patients, clinical and paraclinical team regarding spinal cord injury needs to be addressed. Safe mode of transportation of spinal cord injured patient and early presentation at tertiary spinal care center with comprehensive spinal trauma care team should be stressed upon.

Background: Traumatic cervical spinal cord injury with subaxial fracture and dislocation not only indicates a highly unstable spine but can also induce life-threatening complications. This makes first aid critically important before any definitive operative procedure is undertaken. The present study analyzes the various first aid measures and operative procedures for such injury. Materials and Methods: Two hundred and ninety-five patients suffered from cervical spinal cord injury with fracture and dislocation. The average period between injury and admission was 4.5 days (range 5 h-12 weeks). The injury includes burst fractures ( n = 90), compression fractures with herniated discs ( n = 50), fractures and dislocation ( n = 88) and pure dislocation ( n = 36). Other injuries including developmental spinal canal stenosis and/or multi-segment spinal cord compression associated with trauma ( n = 12), lamina fractures compressing the spinal cord ( n = 6), ligament injuries ( n = 7) and hematoma ( n = 6) were observed in the present study. The injury level was C4 ( n = 17), C5 ( n = 29), C6 ( n = 39), C7 ( n = 35), C4-5 ( n = 38), C5-6 ( n = 58), C6-7 ( n = 49), C4-6 ( n = 16) and C5-7 ( n = 14). According to the Frankel grading system, grade A was observed in 20 cases, grade B in 91, grade C in 124 and grade D in 60. One hundred and eighteen (40%) patients had a high fever and difficulty in breathing on presentation. First aid measures included early reduction and immobilization of the injured cervical spine, controlling the temperature, breathing support,and administration of high-dose methylprednisolone within eight hours of the injury ( n = 12) and administration of dehydration and neurotrophy medicine. Oxygen support was given and tracheotomy was performed for patients with serious difficulty in breathing. Measures were taken to prevent bedsores and infections of the respiratory and urological systems. Two hundred and thirty six patients were treated with anterior decompression, 31 patients were treated by posterior approach surgery and combined anterior and posterior approach surgery was performed in a single sitting on 28 patients. Results: All patients were followed for 0.5-18 years (mean 11.8 years). At least one Frankel grade improvement was observed in 178 (60.3%) patients. In the anterior surgery group, the best results were observed in the cases with slight compressive fracture with disc herniation (44/50 patients, 88.0%). In the posterior surgery group, one Frankel grade improvement was observed in the cases with developmental spinal canal stenosis with trauma, lamina fractures, ligament injuries and hematoma (27/31, 87.1%). Most of the patients in the Frankel D group recovered normal neurological function after surgery. The majority of the patients with Frankel C neurological deficit (102/124) had the ability to walk postoperatively, while most of the seriously injured patients (Frankel A and B) had no improvement in their neurological function. Radiolographic fusion of the operated segments occurred in most patients within three months. Loss of intervertebral height and cervical physiological curvature was observed to varying degrees in 30.1% (71/236) of the cases in the anterior surgery group. Conclusion: First aid measures of early closed reduction or realignment and immobilization of the cervical spine, breathing support and high-dose methylprednisolone were most important in the treatment for traumatic spinal cord injury. Surgery should be performed as soon as the indications of spinal injury appear. The choice of the approach-anterior, posterior or both, should be based on the type of the injury and the surgeon's experience. Any complications should be actively prevented and treated.

Background: There are very few published reports of upper cervical spine injuries from our country and there is a heavy bias towards operative treatment of these injuries. We present below our experience of upper cervical injuries over the last four years. Materials and Methods: Twenty eight patients (20 males, 8 females) with upper cervical spine injury (including Occiput, Atlas and Axis) were treated and were followed-up for an average of 11.2 months. The data was analyzed retrospectively with regards to the location and type of injury, the treatment offered (conservative or operative) as well as the final clinical and radiological outcome. Results: The clinico-radiological outcome of treatment of these injuries is mostly very good with few complications. Other than a single case of mortality due to associated head injury there were no major complications. Conclusion: Management of these patients needs a proper evaluation to arrive at the type of injury and prompt conservative or operative treatment. Treatment is usually safe and effective with good clinical and radiological outcome.

Background: Pedicle screw fixation is the most preferred method of stabilizing unstable spinal fractures. Pedicle screw placement may be difficult in presence of fractured posterior elements, deformed spine, gross instability and spinal pathology. Challenging spine-fracture fixation is defined as the presence of one or more of the following: 1) obscured topographical landmarks as in ankylosing spondylitis, 2) fractures in occipitocervical or cervicothoracic regions and 3) preexisting altered spinal alignment. We report a series of pedicle screw insertion with guidance of navigation in difficult fixation problems.. Materials and Methods: Fourteen patients [hangman's fracture (n=3), odontoid fracture (n=4), C1C2 fracture (n=1) and spinal fracture with coexistent ankylosing spondylitis (n=6)] underwent posterior stabilization. Intraoperatively after surgical exposure, images were acquired by Iso-C 3D C-arm and transferred to navigation system. Instrumentation was performed with navigational assistance. Postoperatively, placements of pedicle screws were evaluated with radiographs and CT scan. Results: Sixty-seven pedicle screws (cervical, n=33; thoracic, n=6; lumbar, n=26; sacral n=2) and 15 lateral mass screws were inserted with navigation guidance. The average time of image data acquisition by Iso-C 3D C-arm and its transfer to workstation was 4 minutes (range, 2-6 minutes). Postoperative CT scan revealed ideal placement of screws in 63 pedicles (94%), grade 1 cortical breaches (<2 mm) in 3 pedicles (4.5%) and grade 2 cortical breach (2-4 mm) in one pedicle (1.5%). There were no neurovascular complications. Deep infection was encountered in one case, which settled with debridement. Conclusions: Intraoperative Iso-C 3D C-arm based navigation is a useful adjunct while stabilizing challenging spinal trauma, rendering feasibility, accuracy and safety of pedicle screw placement even in difficult situations.

Background: Transarticular screw placement needs highly accurate imaging. We assess the efficacy and accuracy of C1-C2 transarticular screw fixation using neuronavigation and also cast a technical note on the procedure. Materials and Methods: This study included a total of nine patients who underwent transarticular screw fixation using the neuronavigation system. A total of 15 screws were placed. All patients underwent postoperative CT scan with 3-Dimensional (3-D) reconstruction to check for the accuracy of implantation. Results: One patient had encroachment of the transverse foramen but there was no vertebral artery injury. There were no clinical complications or adverse sequelae. Conclusion: Neuronavigation is extremely helpful in C1-C2 transarticular screw fixation and gives excellent accuracy.

Background: Despite numerous attempts at classifying thoracolumbar spinal injuries, there remains no consensus on a single unifying algorithm of management. The ideal system should provide diagnostic and prognostic information, exhibit adequate reliability and validity and be easily applicable to clinical practice. The purpose of this study is to assess the reliability and validity of two novel classification systems for thoracolumbar fractures - the Thoracolumbar Injury Severity Score (TLISS) and the Thoracolumbar Injury Classification and Severity Score (TLICS) - and also to discuss potential efforts towards research in the future. Matereials and Methods: Seventy-one patients with thoracolumbar fractures were prospectively assessed by surgeons with different levels of training and experience (attending orthopedic surgeon, attending neurosurgeon, spine fellows, senior level and junior level residents) at a single institution. Plain radiographs, CT and MRI imaging were used to classify these injuries using the TLISS system. Seven months later, 25 consecutive injuries were prospectively assessed with the TLISS and TLICS systems. Unweighted Cohen's kappa coefficients and Spearman's correlation values were calculated to assess inter-observer reliability and validity at each point in time. Results: For both the TLISS and TLICS algorithms, the inter-rater kappa statistics for all of the subgroups demonstrated moderate-to-substantial reliability (0.45-0.74), although there were no significant differences among the shared subgroups. The kappa score of the TLISS system was greater than that of the TLICS system for injury mechanism/ morphology. Correlation values were also greater across all subgroups ( P ≤0.01). Statistically significant improvements in TLISS inter-observer reliability were observed across all TLISS fields ( P <0.05). The TLISS and TLICS schemes both demonstrated excellent validity. Conclusion: The TLISS and TLICS scales both exhibited substantial reliability and validity. However, the TLISS system displayed greater inter-observer correlation than did the TLICS and demonstrated significant improvements in reliability over time.

Background: Advanced diagnostic tools, classification systems and accordingly selected surgical approaches are essential requirements for the prevention of failure of surgical treatment of thoracolumbar fractures. The present study is designed to evaluate the contribution of classification to the choice of a surgical approach using the current fracture classification systems. Materials and Methods: We studied prospectively a group of 64 patients (22 females, 42 males) of an average age of 43 years, all operated on for thoracolumbar fractures during the year 2001. The AO-ASIF classification was used preoperatively with all imaging studies (X-ray, computed tomography (CT) and magnetic resonance imaging (MRI)). When the damage was detected only in the anterior column (A type), an isolated anterior stabilization (n=22) was preferred. If the MRI study disclosed an injury in the posterior column, a posterior approach (n=20) using the internal fixator was chosen. Injuries involving the posterior column (B or C type) were classified additionally according to the load-sharing classification (LSC). If LSC gave six or more points, treatment was completed with an anterior fusion. The combined postero-anterior procedure was carried out 22 times. The minimum followup period was 22 months. Results: Neither implant failure and nor significant loss of correction were observed in patients treated with anterior or combined procedures. The average loss of correction (increase of kyphosis) in simple posterior stabilization was 3.1 degree. Conclusion: Complex fracture classification helps in the selection of the surgical approach and helps to decrease the chances of treatment failure.

Background : Spinal fractures can be an important cause for disabling back pain. Therefore, in judging the cost-effectiveness of nonsurgical or surgical therapy, not only direct costs but also the indirect costs should be calculated. In this prospective randomized study, the costs incurred by nonsurgically and surgically treated patients with a traumatic thoracolumbar spine fracture without neurological involvement were analysed. Materials and Methods : 32 patients with a traumatic thoracolumbar spine fracture were prospectively randomized for operative or nonsurgical treatment. Patients were sent a questionnaire every three months to inquire about work-status, additional health costs and doctor visits. The patients who have minimum followup of two years were included. Results : Of thirty-two patients, 30 met the criterion of the followup period of at least two years. Fourteen patients received nonsurgical therapy, while 16 received surgical treatment. Direct costs of the treatment of nonsurgically treated patients were €10,608 ($12,730). For the operatively treated group, these costs were €18,769 ($22,523). Indirect costs resulted in a total of €219,187 ($263,025) per nonoperatively treated patient. In the operatively treated group, these costs were €66,004 ($79,206). Conclusion: In the treatment of traumatic thoracolumbar spine fractures, the indirect costs exceed the direct costs by far and make up 95.4% of the total costs for treatment in nonsurgically treated patients and 71.6% of the total costs in the operative group. In view of cost-effectiveness, the operative therapy of traumatic thoracolumbar spine fractures is to be preferred.

Background : A short vertebral arthrodesis has been one of the objectives of the surgical treatment of fractures of the thoracolumbar spine. We present here clinical, functional and radiographic outcome obtained after monosegmental fixation (single posterior or combined anterior and posterior) of specific types of unstable thoracolumbar fractures. Materials and Methods : Twenty four patients with fractures of the thoracolumbar spine submitted to monosegmental surgical treatment (Group I - 18 single posterior monosegmental fixations and Group II - 6 combined anterior and posterior fixations) were retrospectively evaluated according to clinical, radiographic and functional parameters. The indication for surgery was instability or neurological deficit. All the procedures were indicated and performed by the senior surgeon (Helton LA Defino). Results : The patients from group I were followed-up from 2 to 12 years (mean: 6.65±2.96). The clinical, functional and radiographic results show that a single posterior monosegmental fixation is adequate and a satisfactory procedure to be used in specific types of thoracolumbar spine fractures, The patients from group II were followed-up from 9 to 15 years (mean: 13 ± 2,09 years). On group II the results of clinical evaluation showed moderate indices of residual pain and of satisfaction with the final result. The values obtained by functional evaluation showed that 66.6% of the patients were unable to return to their previous job and presented a moderate disability index (Oswestry = 16.6) and a significant reduction of quality of life based on the SF-36 questionnaire. Radiographic evaluation showed increased kyphosis of the fixed vertebral segment during the late postoperative period, accompanied by a reduction of the height of the intervertebral disk. Conclusion : It is possible to stabilize the fractures which have an anterior good load-bearing capacity by a standalone posterior monosegmental fixation. However this procedure, even with an anterior support is not suitable for fracture involving the vertebral body.

Background : Controversy continues regarding the best treatment for compression and burst fractures. The axial distraction reduction utilizing the technique employing the long straight rod or curved short rod without derotation to reduce fracture are practised together with short segment posterolateral fusion (PLF). Effects of the early postoperative mobilization without posterolateral fusion on reduction maintenance and fracture consolidation were not evaluated so far. The present prospective study is designed to assess the effectiveness of i) reduction and restoration of sagittal alignment, ii) no posterolateral fusion on the reduced, fractured vertebral body and injured disc, iii) fracture consolidation and iv) the fate of the unfused cephalad and caudal injured motion segments of the fractured vertebra. Materials and Methods : The study includes 15 Denis burst and two Denis type D compression fractures between T ₁₂ and L ₃ . The lordotic distraction technique was used for ligamentotaxis utilizing the contoured short rods and pedicle screw fixator. Three vertebrae including the fractured one were fixed. The patients after surgery were braced for ten weeks with activity restriction for 2-4 weeks. The patients were evaluated for change in vertebral body height, sagittal curve, reduction of retropulsion, improvement in neural deficit. The unfused motion segments, residual postoperative pain and bone and metal failure were also evaluated. Results : The preoperative and postreduction percentile vertebral heights at, zero (immediate postoperative), at three, six and 12 months followup were 62.4, 94.8, 94.6, 94.5 and 94.5%, respectively. The percentages of the intracanal fragment retropulsion at preoperative, and postoperative at zero, 3, 6 and 12 months followup were 59.0, 36.2,, 36.0, 32.3, and 13.6% respectively. The preoperative and postreduction percentile loss of the canal dimension and at zero, three, six and 12 months were 52.1, 45.0, 44.0, 41.0 and 29% respectively suggesting that the under-reduced fragment was being resorbed gradually by a remodeling process. The mean initial kyphosis of 33° became mean 2° immediately after reduction and mean 3° at the final followup. The fractured vertebral bodies consolidated in an average period of ten weeks (range 8-14 weeks). The restored disc heights were relatively well maintained throughout the observation period. All paraparetic patients recovered neurologically. There were no postoperative complications. Conclusion : Instrument-aided ligamentotaxis for compression and burst fractures utilizing the short contoured rod derotation technique and the instrumented stabilization of the fractured spine are found to be effective procedures which contribute to the fractured vertebral body consolidation without recollapse and maintain the motion segment function.

Background: In the surgical treatment of thoracolumbar fractures, the major problem after posterior correction and transpedicular instrumentation is failure to support the anterior spinal column, leading to loss of correction and instrumentation failure with associated complaints. We conducted this prospective study to evaluate the outcome of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty, grafting with calcium phosphate cement and short pedicle screw fixation plus fusion. Materials and Methods : Twenty-three consecutive patients of thoracolumbar (T ₉ to L ₄ ) burst fracture with or without neurologic deficit with an average age of 43 years, were included in this prospective study. Twenty-one from the 23 patients had single burst fracture while the remaining two patients had a burst fracture and additionally an adjacent A1-type fracture. On admission six (26%) out of 23 patients had neurological deficit (five incomplete, one complete). Bilateral transpedicular balloon kyphoplasty with liquid calcium phosphate to reduce segmental kyphosis and restore vertebral body height and short (three vertebrae) pedicle screw instrumentation with posterolateral fusion was performed. Gardner kyphosis angle, anterior and posterior vertebral body height ratio and spinal canal encroachment were calculated pre- to postoperatively. Results : All 23 patients were operated within two days after admission and were followed for at least 12 months after index surgery. Operating time and blood loss averaged 45 min and 60 cc respectively. The five patients with incomplete neurological lesions improved by at least one ASIA grade, while no neurological deterioration was observed in any case. The VAS and SF-36 (Role physical and Bodily pain domains) were significantly improved postoperatively. Overall sagittal alignment was improved from an average preoperative 16° to one degree kyphosis at final followup observation. The anterior vertebral body height ratio improved from 0.6 preoperatively to 0.9 ( P <0.001) postoperatively, while posterior vertebral body height improved from 0.95 to 1 ( P <0.01). Spinal canal encroachment was reduced from an average 32% preoperatively to 20% postoperatively. Cement leakage was observed in four cases (three anterior to vertebral body and one into the disc without sequalae). In the last CT evaluation, there was a continuity between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within six months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients. Conclusions : Balloon kyphoplasty with calcium phosphate cement secured with posterior short fixation in the thoracolumbar spine provided excellent immediate reduction of posttraumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level.

Background: Short-segment fixation alone to treat thoracolumbar burst fractures is common but it has a 20-50% incidence of implant failure and rekyphosis. A transpedicle body augmenter (TpBA) to reinforce the vertebral body via posterior approach has been reported to prevent implant failure and increase the clinical success rate in treating burst fracture. This article is to evaluate the longterm results of short-segment fixation with TpBA for treatment of thoracolumbar burst fractures. Materials and Methods: Patients included in the study had a single-level burst fracture involving T11-L2 and no distraction or rotation element with limited neurological deficit. Patients in the control group (n = 42) were treated with short-segment posterior instrumentation alone, whereas patients in the augmented group (n = 90) were treated with a titanium spacer designed for transpedicle body reconstruction. The followup was 48-101 months. The radiographic and clinical results were evaluated and compared by Student's t test and Fisher's exact test. Results: The blood loss, operation time and hospitalization were similar in both the groups. The immediate postoperative anterior vertebral restoration rate of the augmented group was similar to that of the control group (97.6% ± 2.4% vs . 96.6% ± 3.2%). The final anterior vertebral restoration was greater in the augmented group than in the control group (93.3% ± 3.4% vs . 62.5% ± 11.2%). Immediate postoperative kyphotic angles were not significantly different between the groups (3.0° ± 1.8° vs . 5.1° ± 2.3°). The final kyphotic angles were less in the augmented group than the control group (7.3° ± 3.5° vs . 20.1° ± 5.4°). The augmented group had less ( P < 0.001) implant failure [0% (n=0) vs . 23.8% (n=10)] for the control group) and more patients ( P < 0.001) with no pain or minimal or occasional pain (Grade P1 or P2) than the control group [90.0% (n=81) vs . 66.7% (n=28)]. All patients in the augmented group and 39 (92.8%) patients in the control group experienced neurological recovery to Frankel Grade E. Three patients in the control group had improvement to Frankel Grade D from Frankel Grade C, but later had deterioration to Frankel Grade C because of loosening and dislodgement of the implant. Conclusion: Posterior body reconstruction with TpBA can maintain kyphosis correction and vertebral restoration, prevent implant failure and lead to better clinical results.

Background: The major problem after posterior correction and instrumentation in the treatment of thoracolumbar burst fractures is failure to support the anterior spinal column leading to loss of correction of kyphosis and hardware breakage. We conducted a prospective consecutive series to evaluate the outcome of the management of acute thoracolumbar burst fractures by transpedicular hydroxyapatite (HA) grafting following indirect reduction and pedicle screw fixation. Materials and Methods: Eighteen consecutive patients who had thoracolumbar burst fractures and associated incomplete neurological deficit were operatively treated within four days of admission. Following indirect reduction and pedicle screw fixation, transpedicular intracorporeal HA grafting to the fractured vertebrae was performed. Mean operative time was 125 min and mean blood loss was 150 ml. Their implants were removed within one year and were prospectively followed for at least two years. Results: The neurological function of all 18 patients improved by at least one ASIA grade, with nine (50%) patients demonstrating complete neurological recovery. Sagittal alignment was improved from a mean preoperative kyphosis of 17°to -2°(lordosis) by operation, but was found to have slightly deteriorated to 1° at final followup observation. The CT images demonstrated a mean spinal canal narrowing preoperatively, immediate postoperative and at final followup of 60%, 22% and 11%, respectively . There were no instances of hardware failure. No patient reported severe pain or needed daily dosages of analgesics at the final followup. The two-year postoperative MRI demonstrated an increase of one grade in disc degeneration (n = 17) at the disc above and in 11 patients below the fractured vertebra. At the final followup, flexion-extension radiographs revealed that a median range of motion was 4, 6 and 34 degrees at the cranial segment of the fractured vertebra, caudal segment and L1-S1, respectively. Bone formation by osteoconduction in HA granules was unclear, but final radiographs showed healed fractures. Conclusions: Posterior indirect reduction, transpedicular HA grafting and pedicle screw fixation could prevent the development of kyphosis and should lead to reliable neurological improvement in patients with incomplete neurological deficit. This technique does not require fusion to a segment, thereby preserves thoracolumbar motion.

Polytraumatized patients following a severe trauma suffer from substantial disturbances of the immune system. Secondary organ dysfunction syndromes due to early hyperinflammation and late immunparalysis contribute to adverse outcome. Consequently the principle of damage control surgery / orthopedics developed in the last two decades to limit secondary iatrogenic insult in these patients. New percutaneous internal fixators provide implants for a damage control approach of spinal trauma in polytraumatized patients. The goal of this study is to evaluate the feasibility of minimal-invasive instrumentation in the setting of minor and major trauma and to discuss the potential benefits and drawbacks of this procedure. Materials and Methods: The present study is a prospective analysis of 76 consecutive patients (mean age 53.3 years) with thoracolumbar spine fractures following major or minor trauma from August 2003 to January 2007 who were subjected to minimal-invasive dorsal instrumentation using CD Horizon^® Sextant ^TM Rod Insertion System and Longitude ^TM Rod Insertion System (Medtronic^® Sofamor Danek). Perioperative and postoperative outcome measures including e.g. local and systemic complications were assessed and discussed. Results: Forty-nine patients (64.5%) suffered from minor trauma (Injury Severity Score <16). Polytraumatized patients (n=27; 35.5%) had associated chest (n=20) and traumatic brain injuries (n=22). For mono- and bisegmental dorsal instrumentation the Sextant ^TM was used in 60 patients, whereas in 16 longer ranging instrumentations the (prototype) Longitude ^TM system was implanted. Operation time was substantially lower than in conventional approach at minimum 22.5 min for Sextant and 36.2 min for Longitude ^TM , respectively. Geriatric patients with high perioperative risk according to ASA classification benefited from the less invasive approach and lack of approach-related complications including no substantial blood loss. Conclusion: Low rate of approach-related complications in association with short operation time and virtually no blood loss is beneficial in the setting of polytraumatized patients regarding damage control orthopedics, as well as in geriatric patients with high perioperative risk. The minimal-invasive instrumentation of the spine is associated with beneficial outcome in a selected patient population.

Background: Management of femoral diaphyseal fractures in the age group of 6-16 years is controversial. There has been a resurgence worldwide for operative fixation. Materials and Methods: Twenty-two children (18 boys, 4 girls) aged 6-16 years with recent (<3 days) femoral diaphyseal fractures (20 closed, 2 open) were stabilized with Titanium Elastic Nail (TEN). These fractures were in proximal third (n=3), middle third (n=15) and in the distal third (n=4) 17 patients underwent surgery within seven days of their injury. The results were evaluated using Flynn's scoring criteria. Statistical analysis was done using Fischer's exact test. Results : All 22 patients were available for evaluation after a mean of 26 months (14-36 months) of followup. Radiological union in all cases were achieved in a mean time of 8.7 weeks. Full weight bearing was possible in a mean time of 8.8 weeks. Mean duration of hospital stay was 9.8 days. The results were excellent in 13 patients (59.0%), successful in six (27.2%) and poor in three patients (13.6%). All patients had early return to school. Conclusion : Intramedullary fixation titanium elastic nailing is an effective treatment of diaphyseal fractures of the femur in properly selected patients of the 6-16 years age group.

Background: Supracondylar fractures associated with ipsilateral forearm fractures, aptly termed as "floating elbow" is a rare injury in children after a fall from height. The various authors have reported their results with conservative treatment of one or both injuries to aggressive emergency operative fixation of both components. Materials and Methods: During a period of three years, the author managed four cases of floating elbow in children. All cases were managed by closed reduction and pinning of both components of the injury. Results: All patients recovered full elbow range of motion at three months followup and were rated as excellent as per modified Flynn's criteria. None of the patients developed cubitus varus deformity, complications related to the pins or delayed union. Conclusions: Early closed reduction and K wire fixation of both components of this injury gives better stability and prevents development of complications like compartment syndrome and elbow deformities.

Background : Stiffness of the knee after trauma and/or surgery for femoral fractures is one of the most common complications and is difficult to treat. Stiffness in extension is more common and can be reduced by vigorous physiotherapy. If it does not improve then quadricepsplasty is indicated. The present study was undertaken to evaluate the results of Thompsons quadricepsplasty. Materials and Methods : Twenty-two male patients (age range 20-45 years) with posttraumatic knee stiffness following distal femoral fractures underwent Thompson's quadricepsplasty where knee flexion range was less than 45°. The index injury in these patients was treated with plaster cast (n=5), plates (n=3), intramedullary nailing (n=3) and external fixator for open fractures (n=9). Thompson's quadricepsplasty was performed in all the patients using anterior approach, with incision extending from the upper thigh to the tibial tubercle. Release of rectus femoris from underlying vastus intermedius and release of intraarticular adhesions were performed. After surgery the patients needed parenteral analgesia for three days and then oral analgesics for three weeks. Active assisted knee mobilization exercises was started on the first postoperative day. Continuous passive motion machine was used from the same day. Supervised physiotherapy was continued in hospital for six weeks followed by intensive knee flexion and extension exercise including cycling at home for atleast another six months. Results : Out of 22 patients, 20 had excellent to good results and two patients had poor results using criteria devised by Judet. One poor result was due to peroperative fracture of patella which was then internally fixed and hence the flexion of knee could not be started immediately. There was peroperative avulsion of tibial tuberosity in another patient who finally gained less than 50° knee flexion and hence a poor result. Conclusion : Thompsons quadricepsplasty followed by a strict and rigourous postoperative physiotherapy protocol successfully increases the range of knee flexion.

Intramedullary epidermoid cysts of the spinal cord are rare tumors, especially those not associated with spinal dysraphism. About 50 cases have been reported in the literature. Of these, only seven cases have had magnetic resonance imaging (MRI) studies. We report two cases of spinal intramedullary epidermoid cysts with MR imaging. Both were not associated with spina bifida. In one patient, the tumor was located at D4 vertebral level; while in the other, within the conus medullaris. The clinical features, MRI characteristics and surgical treatment of intramedullary epidermoid cyst are presented with relevant review of the literature.

Progressive post-traumatic cystic syringomyelia is an uncommon and increasingly recognized cause of morbidity following spinal cord injury. We hereby report a 35-year-old gentleman who sustained wedge compression fracture of L-1 vertebral body 15 years back and had complete paraplegia with bowel/bladder involvement. The neurological deficit recovered with minimal residual motor deficits and erectile dysfunction. He presented now with increasing neurological deficits associated with pain and paresthesia. The MRI spine showed a syrinx extending from the site of injury up to the medulla. He underwent a syringo-peritoneal shunt and at followup his pain and motor functions had improved but erectile dysfunction was persisting.

We describe a case of sacral perineural cyst presenting with complaints of low back pain with neurological claudication. The patient was treated by laminectomy and excision of the cyst. Tarlov cysts (sacral perineural cysts) are nerve root cysts found most commonly in the sacral roots, arising between the covering layer of the perineurium and the endoneurium near the dorsal root ganglion. The incidence of Tarlov cysts is 5% and most of them are asymptomatic, usually detected as incidental findings on MRI. Symptomatic Tarlov cysts are extremely rare, commonly presenting as sacral or lumbar pain syndromes, sciatica or rarely as cauda equina syndrome. Tarlov cysts should be considered in the differential diagnosis of patients presenting with these complaints.

A nine years old boy, who had suffered septic arthritis at the age of two years and presented now with a limp, hip instability, leg length discrepancy. The patient was treated by adductor tenotomy and upper tibial pin traction. When head remnant reached the level of the acetabulum, open reduction and Pemberton osteotomy was done to achieve cover of the femoral head. The purpose of this report is to highlight the six years followup of reconstruction of sequale of septic arthritis of hip joint.