Proceedings of the NASS 28th Annual Meeting / The Spine Journal 13 (2013) 1S–168S
treatment. Inclusion criteria included appropriate initial imaging, lab re-
sults, evaluation by the orthopedic department, and no treatment done prior
to admission at an outside institution. Chi-squared statistic, Fisher’s exact,
and single sample t tests were used to examine the data. All patient char-
acteristics were evaluated as potential risk factors. A delay of diagnosis
was defined as greater than 8 weeks from first ER visit to diagnosis. Clear-
ance of the infection was defined as normalizing of serum markers and res-
olution of osteomyelitis on MRI after 6 months of treatment.
RESULTS: One-hundred six patients met the inclusion criteria with 151
admissions and readmissions specifically for the management of vertebral
osteomyelitis: 62 men (58%), 44 women (42%), mean age 54 yrs., mean
follow-up 38 months. The risk factors for delay in diagnosis were HIV
(odds ratio, OR: 2.0, n 5 14), hepatitis C (OR: 2.06, n 5 26), intravenous
drug abuse (IVDA, OR 2.11, n 5 36), and tuberculosis (TB, OR: 2.75,
n 525). In patients with a delayed diagnosis, the mean time to diagnosis
was 2.3 months (SD62.4). The early diagnosis cohort (ED) tended to clear
the infection more often than the delayed diagnosis cohort (DD) and
trended toward significance [OR 2.6, 95% CI: 0.96 to 7.07, p 5 0.057].
The Oswestry scores from initial presentation to final follow-up respec-
tively: ED5 62.9 (SD6 16.9) and 49.2 (SD614.8), DD5 67.4 (SD618)
and 45.2 (SD621). The mean cost of hospital admission was less in the
ED group ($158,294) compared to DD group ($190,286).
CONCLUSIONS: Risk factors for a delay in diagnosis for vertebral oste-
omyelitis are HIV, hepatitis C, IVDA and TB. An increased level of suspi-
cion for vertebral osteomyelitis is needed in these populations. These cases
of delayed diagnosis progressed to chronic osteomyelitis that was refrac-
tory to nonoperative care and accrued higher hospital costs. However,
long-term improvement in Oswestry scores was not affected by a delayed
diagnosis.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include
any applicable devices or drugs.
http://dx.doi.org/10.1016/j.spinee.2013.07.137
90. Spinal Epidural Abscesses: Risk Factors, Medical versus Surgical
Management: A Retrospective Review of 128 Cases
Timothy B. Alton, MD1, Amit R. Patel, MD1, Richard J. Bransford, MD2,
Carlo Bellabarba, MD3, Michael J. Lee, MD4, Jens R. Chapman, MD2;
1
Seattle, WA, US; 2UW Harborview Medical Center, Seattle, WA, US;
3
University of Washington, Seattle, WA, US; 4Department of Orthopaedic
Surgery, Seattle, WA, US
BACKGROUND CONTEXT: Spinal epidural abscess (SEA) is a rare, se-
rious and increasingly frequent diagnosis. Ideal management (medical vs
surgical) remains controversial.
PURPOSE: The purpose of this study is to assess the impact of risk fac-
tors, organisms, location and extent of SEA on neurological outcome
after medical management or surgery in combination with medical
management.
STUDY DESIGN/SETTING: Retrospective electronic medical record
(EMR) review.
PATIENT SAMPLE: 128 consecutive spontaneous SEA from a single
tertiary medical center, Jan 05-Sept 11, 79 male, 49 female, age 22-83 years
(mean 52.9).
OUTCOME MEASURES: Patient demographics, presenting complaints,
radiographic features, pre/post-treatment neurological status (ASIA motor
score [MS] 0-100), treatment (medical vs surgical) and clinical follow-up
were recorded. Neurological status was determined before treatment and at
last available clinical encounter. Imaging studies reviewed location/extent
of pathology.
METHODS: Inclusion criteria: diagnosis of a bacterial SEA based on ra-
diographs and/or intraop findings, age O18 years, and adequate EMR. Ex-
clusion criteria: post interventional infections, Pott’s disease, isolated
discitis/osteomyelitis, treatment initiated at an outside facility, and imaging
suggestive of a SEA but negative intra-op findings/cultures.
Refer to onsite Annual Meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately
reporting disclosures and FDA device/drug status at time of abstract submission.
45S
RESULTS: Mean follow-up 241 days. Presenting chief complaint: site-spe-
cific pain (100%), subjective fevers (50%), weakness (47%). 54.7% had
lumbar, 39.1% thoracic, 35.9% cervical and 23.4% sacral involvement span-
ning an average of 3.85 disc levels. 36% ventral, 41% dorsal, 23% circum-
ferential. Risk factors: history of IV drug abuse (39.1%), diabetes mellitus
(21.9%) and no risk factors (22.7%). Pathogen: MSSA (40%), MRSA
(30%). Location, SEA extent and pathogen did not impact MS recovery.
51 patients were treated with antibiotics alone (group 1), 77 with surgery
and antibiotics (group 2). Within group 1, 21 patients (41%) failed medical
management (progressive MS loss or worsening pain) requiring delayed
surgery (group 3). Irrespective of treatment, MS improved 3.37 points. 30
patients had successful medical management (MS: pre-treatment 96.5,
post-treatment 96.8). 21 patients failed medical therapy (41%), (MS: pre-
treatment 99.86, decreasing to 76.2 (mean change -23.67 points), post-sur-
gery improvement to 85.0, net deterioration of -14.86 points). This is signif-
icantly worse than the mean improvement of immediate surgery (group 2)
(MS: pretreatment 80.32, post-treatment 89.84, recovery of 9.52 points). Di-
abetes mellitus, CRP O115, WBC O12.5 and positive blood cultures predict
medical failure; 0 of 4 parameters: 8.3% failure; 1 parameter: 35.4% failure;
2 parameters: 40.2% failure; 3 or more parameters: 76.9% failure.
CONCLUSIONS: Early surgery improves neurological outcomes com-
pared with surgical treatment delayed by a trial of medical management.
Over 41% of patients treated medically failed management and required
surgical decompression. Diabetes, CRP O115, WBC O12.5, and bacter-
emia predict failure of medical management. If a SEA is to be treated med-
ically, great caution and vigilance must be maintained. Otherwise, early
surgical decompression, irrigation, and debridement should be the main-
stay of treatment.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include
any applicable devices or drugs.
http://dx.doi.org/10.1016/j.spinee.2013.07.138
Thursday, October 10, 2013
4:10 – 5:10 PM
Concurrent Session: Trauma
91. Floating Lateral Mass Fractures of the Cervical Spine
Richard J. Bransford, MD1, Mark W. Manoso, MD2, Carlo Bellabarba,
MD3; 1Harborview Medical Center, Seattle, WA, US; 2University of
Washington Medicine Sport and Spine Physicians, Seattle, WA, US;
3
University of Washington, Seattle, WA, US
BACKGROUND CONTEXT: A rare subset of lateral mass fractures is
the floating lateral mass fracture (FLM) with fractures of the adjacent ped-
icle and lamina. To our knowledge, no peer reviewed literature has focused
on this unique fracture pattern and, therefore, our understanding of this
particular injury and how best to manage it is very limited.
PURPOSE: To describe this important subset in regard to the mechanisms
of injury, associated injuries, vascular injuries, neurological deficits, key
radiographic features and the type of stabilization required.
STUDY DESIGN/SETTING: Retrospective study.
PATIENT SAMPLE: Consecutive patients with FLM fractures from 2007
to 2012.
OUTCOME MEASURES: The primary goal was to describe this injury.
The secondary goal was to assess effectiveness of management with out-
come of maintenance of alignment.
METHODS: A retrospective study of all FLMs treated at a level I
trauma center from 2007 to 2012 was performed. All medical records
and spinal imaging studies were reviewed focusing primarily on mecha-
nism, clinical presentation and radiographic findings. Management of the
injury was assessed as well as outcomes of maintenance of alignment to
final follow-up.
46S Proceedings of the NASS 28th Annual Meeting / The Spine Journal 13 (2013) 1S–168S
RESULTS: Following institutional review board approval, 32 consecutive
cases were identified from the prospectively collected trauma registry. The
mean follow-up was 6 months (2-42 months). Mean age was 31 years
(16-69). The most common levels were C6 (50%) and C5 (34%). The most
common mechanisms of injury were high speed motor vehicle accident
(68%) and sports injury (19%). A nondisplaced pattern in supine films oc-
curred in 25%. Rotational displacement manifested as a grade 1anterolis-
thesis in 83% at the level below the injury, 8% at the level above and 8% at
both levels. CT showed facet joint widening at the level above and below
in 72%, below only in 16%, and above only in 9%. Vertebral artery injuries
(VAI) occurred in 25%. MRI (21 pts) demonstrated injury to the lower disc
level in 76%, to the level above 10%, and a herniated disc in 24%. Neuro-
logical deficits (ND) occurred as radiculopathy in 22% and spinal cord in-
jury in 19%. CHI, visceral injury, and other fractures occurred in 25%,
25% and 41%, respectively. All 3 patients, who were treated nonopera-
tively, developed subluxation despite external immobilization and required
surgery. Of the 32 patients treated operatively, 19 (59%) patients under-
went a 2-level anterior cervical discectomy and fusion (ACDF) alone, with
no failures. 6(19%) patients had a 1-level ACDF, with a 50% radiographic
failure with progression of translation and rotation at the adjacent level re-
quiring additional surgery. Posterior spinal instrumented fusion (PSIF)
alone was performed in 4 patients. PSIF in combination with ACDF was
performed in 3 (9%). No patients that were followed beyond 6 months
(56%) developed a nonunion.
CONCLUSIONS: An FLM results from a high energy injury and involves
2 motion segments. Vertebral artery injuries and neurological injuries are
common. 86% have disc injury on MR. Two level ACDF or PSIF are ef-
fective means of treatment; non-operative management and single level
surgery led to an unacceptable failure rate.
FDA DEVICE/DRUG STATUS: Lateral Mass Screws (Not approved for
this indication), Anterior Cervical Plating (Approved for this indication)
http://dx.doi.org/10.1016/j.spinee.2013.07.140
92. Early Spine Surgery in the Multiple-Injured Patient:
Implications of Damage Control Criteria
James M. Mok, MD1, Joseph W. Galvin, DO1, Andrew J. Schoenfeld, MD2,
Brett A. Freedman, MD3; 1Madigan Army Medical Center, Tacoma, WA,
US; 2Canutillo, TX, US; 3Landstuhl Regional Medical Center, APO, AE, US
BACKGROUND CONTEXT: Damage control management of the mul-
tipley-injured patient includes delaying definitive fixation of extremity in-
juries to allow adequate resuscitation and prevent Systemic Inflammatory
Response Syndrome. How it applies to spinal trauma remains unclear. The
performance of spine surgery in the Afghanistan theater allows analysis of
the morbidity of early surgery on military casualties, many of whom meet
Damage Control criteria.
PURPOSE: To describe surgical morbidity based on Damage Control
criteria.
STUDY DESIGN/SETTING: Performance Improvement project ap-
proved by the Joint Combat Casualty Research Team, retrospective, mili-
tary treatment facility in theater.
PATIENT SAMPLE: Thirty American and NATO military casualties who
underwent spine surgery in the Afghanistan theater.
OUTCOME MEASURES: Operative time, blood loss, transfusion, neu-
rologic improvement.
METHODS: Clinical data were obtained in retrospective fashion via the
Theater Medical Data Store. Patients were considered ‘‘Stable’’ or ‘‘Dam-
age Control’’ depending on the presence of at least one of the following:
ISSO40, ISSO20 and chest injury, exploratory laparotomy or thoracotomy,
lactateO2.5, platelet! 110,000, O10 units PRBC transfused preop.
RESULTS: Thirty casualties underwent 31 spine surgeries during
a 12 month period. Mean age was 27.49. Mean ISS was 26. Twenty-six
were combat casualties. Spine surgery was performed at a mean 1.41 days
(0.34-3.32) post-injury. Seventeen of 30 patients met Damage Control
Refer to onsite Annual Meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately
reporting disclosures and FDA device/drug status at time of abstract submission.
criteria. Damage Control patients had significantly higher operative time
(mean 4.3 vs 3.0 hours, p50.01), blood loss (1,372 vs 366 mL,
p50.001), PRBC transfused intraop (3.88 vs 0.14 units, p!0.001), and to-
tal PRBC transfused in theater (10.18 vs 0.31 units, p!0.001). Damage
Control patients had significantly lower pre- (10.97 vs 13.75 g/dL,
p50.001) and postoperative Hb (9.98 vs 11.12 g/dL, p!0.05). Improve-
ment in neurologic status, including spinal cord injury, cauda equina syn-
drome or nerve root injury, was considered present in 2 of 17 (12%)
Damage Control patients and 4 of 13 (31%) Stable patients. There was
no significant difference in surgical invasiveness index (7.4 vs 6.7, p50.7).
CONCLUSIONS: Morbidity of early spinal surgery was significantly
higher in Damage Control patients than Stable patients. The results indi-
cate that spine surgery represents a considerable physiologic stress to
a group already at risk for serious complications. When considering early
spine surgery in the multiple-injured patient, the indication, urgency and
extent of the planned procedure should be carefully weighed against poten-
tial morbidity.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include
any applicable devices or drugs.
http://dx.doi.org/10.1016/j.spinee.2013.07.141
93. Routine Analysis of Cervical Angiograms in Cervical Spine
Trauma Patients
Tina Dreger, MD1, Howard M. Place, MD1, Christine C. Piper, BS2,
Theresa K. Mattingly, BS1, Jennifer L. Brechbuhler, BSN1; 1St. Louis
University, St. Louis, MO, US; 2Philadelphia, PA, US
BACKGROUND CONTEXT: Blunt vertebral artery injury (BVAI) is an
example of a previously under-diagnosed injury. The ease of CT angiogra-
phy (CTA) has simplified evaluation for these injuries in the trauma pa-
tient. Blunt injury to the vertebral or carotid arteries is diagnosed in
approximately 0.1% of blunt trauma patients when there is high clinical
suspicion of injury, or when symptoms of central nervous system damage
are apparent on initial examination. Routine screening of asymptomatic
patients increases the incidence to approximately 1%. The more significant
question to address is the value of routine screening and its impact on
patient care.
PURPOSE: The purpose of this study is to assess the effect of routine
CTA for the diagnosis of BVAI in the poly-trauma patient. Emphasis is
placed on indications for the tests, result of the test, and the effects of
the results on treatment of the patient.
STUDY DESIGN/SETTING: This study is a retrospective chart review of
all patients seen at a level one trauma center over a 6 year period of time.
PATIENT SAMPLE: The hospital trauma registry and Emergency De-
partment records of a level one trauma center were reviewed. All patient
records with a documented cervical spine fracture were included in the
initial analysis. The patient sample included all patients who underwent
CTA or MR angiogram (MRA) as well as all patients who had a docu-
mented cervical spine fracture and a potential complication associated
with a possible BVAI such as unilateral hemiplegia or death of unknown
cause.
OUTCOME MEASURES: The results of the diagnostic studies are re-
corded and compared to the results of previously published literature. In
addition, an assessment was made of how the information gained through
these studies aided in management of the patients.
METHODS: After IRB approval, the hospital trauma registry was utilized
to identify patients age 18-89, who presented with cervical spine fracture
over the six year period from 2006-2011. A retrospective review of those
charts was completed. Data collection included routine demographic data,
details of the documented fracture, and neurologic symptoms. The indica-
tions for and the results of CTA in patients was also reviewed. The type of
treatment and complications of the treatment were also recorded. We spe-
cifically assessed complications of the CTA and the resultant treatment of
the BVAI whether active or passive. We also assessed the screened patients