Purpose: The optimal timing for surgical stabilization of the fractured spine is controversial. Early stabilization facilitates earlier mobilization and theoretically reduces associated complications.

Method: Consecutive patients requiring stabilization surgery for a spinal fracture, without neurological injury were identified from a prospective institutional database. Patients were stratified by the time to their final surgical stabilization procedure (< 12, 12–24, 24–48, 48–72 and > 72 hours) and outcomes compared. Multivariate analyses were performed to explore potential confounding effects.

Results: 76 patients satisfied the inclusion/exclusion criteria. The median time to final surgical spinal stabilization was 71.8 hours. There were significant differences in complications related to prolonged recumbancy (e.g. respiratory failure, thromboembolism, p = 0.016) between the different time frames. Graphical exploration suggested higher complication rates after 48 hours delay. Comparing patients stabilized after 48 hours compared to those within, there was a 6.9 times (p = 0.0085) greater risk of a complication related to prolonged recumbancy. These effects remained significant after multivariate adjustments for age, comorbidity and ISS. There were trends towards longer lengths of stay and lower function (measured using the FIM) at discharge in the surgical delay group.

Conclusion: This study demonstrates a strong relationship between surgical delay and complications. The cutoff for this delay appears to occur at 48 hours. This study is limited in that the identified relationship may be related to a number of other confounding factors not measured or inadequately adjusted for because of small numbers. Further study, using this study’s developed algorithms in larger datasets, may help resolve some of these issues.

Purpose: The goal of laminectomy is to relieve spinal stenosis and improve radiculopathy. Back pain related to poor trunk muscular conditioning may negatively affect post-operative outcomes. A better understanding of this relationship is important to improve the selection of appropriate surgical candidates. The purpose of this study was to assess the association between cross-sectional lumbar paraspinal muscle area as measured by CT or MRI and outcomes following laminectomy.

Method: Prospective observational study of 23 patients undergoing primary elective lumbar laminectomy without fusion who were assessed with pre-operative CT scans. Clinical outcomes were measured with Numerical Pain Scale (NPS) for back and leg pain and the Oswestry Low Back Disability Index (ODI) at baseline and follow-up at a minimum of one year. Lumbar paraspinal muscle cross-sectional area was measured using digital imaging software and adjusted for percent fat infiltration; CT scans evaluations were blinded to clinical outcomes.

Results: There were significant improvements in clinical outcomes following laminectomy. ODI decreased from 53.9±11.8 (mean±standard deviation) at baseline to 27.3±20.6 after a follow-up of 15.2±3.5 months. A strong correlation existed between cross-sectional lumbar paraspinal muscle area after adjusting for infiltrating fat content an improvement in ODI (r=0.51, p< 0.02) or back pain NPS (r=0.55, p< 0.02). These relationships remained statistically significant after adjusting for age and body mass index. No significant associations were identified for improvements in leg pain NPS.

Conclusion: This study suggests a possible relationship between cross-sectional lumbar paraspinal muscle area and outcomes following laminectomy. This raises important questions regarding the role of trunk muscular conditioning in the etiology of back pain and success of surgery. Further research is required to refine this measurement as a tool to improve patient selection for surgery.

Although many authors have emphasised the importance of lumbar spinal decompression surgery for “leg dominant pain”, there is little objective evidence on the outcomes of surgery for varying degrees of back pain compared to leg pain. Moreover, it is unclear whether patients with radicular or claudication type leg pain, presenting with significant back pain as well, would benefit from surgical decompression. This study evaluated the outcomes of patients with

(i.) leg dominant pain compared to patients with

A prospective cohort of consenting adult patients, who have consecutively undergone elective primary posterior lumbar decompression surgery at a single academic institution by sub-specialty spinal surgeons were evaluated with longitudinal follow-up using standardised outcomes instruments. The cohort was analyzed into those with

(i.) leg dominant pain and those with

Univariate and multivariate analyses were used to adjust for potential confounding effects of demographic, surgical, waiting list and psychosocial factors.

Of the eighty-five eligible patients, sixty-nine (81.3%) had at least one year follow-up with a mean follow-up time of seventeen months. Baseline factors were similar between the two groups except for back and leg pain and wait times for consultation after referral. Patients with significant back pain waited significantly longer (p = 0.04) for consultation after referral than those with leg dominant pain. Significantly (p = 0.002) more patients (93%) in the leg dominant pain group reported clinically significant improvement in the Oswestry than the significant back pain group (59%). This effect remained after multivariate adjustments for other baseline factors.

This study is one of the first to provide objective evidence to support the notion that the primary indication and best predictor of outcome for lumbar decompression surgery is leg dominant pain. Presence of significant back pain, despite presence of leg pain, is a strong predictor of poorer post-operative results. Further research is required to determine if the current long waiting lists are a causative factor for development of significant back pain in surgical candidates.

Death during the first year after hip fracture may be influenced by the type of hospital in which patients are treated as well as the time spent awaiting surgery. We studied 57 315 hip fracture patients who were admitted to hospital in Ontario, Canada. Patients treated in teaching hospitals had a decreased risk of in-hospital mortality (odds ratio (OR) 0.89; 95% confidence interval (CI) 0.83 to 0.97) compared with those treated in urban community institutions. There was a trend toward increased mortality in rural rather than urban community hospitals. In-hospital mortality increased as the surgical delay increased (OR 1.13; 95% CI 1.10 to 1.16) for a one-day delay and higher (OR 1.60; 95% CI 1.42 to 1.80) for delays of more than two days. This relationship was strongest for patients younger than 70 years of age and with no comorbidities but was independent of hospital status. Similar relationships were seen at three months and one year after surgery. This suggests that any delay to surgery for non-medical reasons is detrimental to a patient’s outcome.

Introduction: Flexion distraction injuries (FDI)of the thoracic and lumbar spine can be stabilized with a short construct spanning one motion-segment. This fracture is functionally defined by failure of the posterior and middle columns in tension and the anterior column in compression or tension. Treatment of a predominantly bony injury with minimal deformity (Chance type) is usually non-operative. Intra-abdominal pathology, and ligamentous spinal instability are relative indications for surgery. Deformity of greater than 17 degrees of kyphosis has a poor prognosis when treated conservatively, and represents true instability in vitro. Surgical treatment is mainly through a posterior approach with instrumentation. Which construct to use and the number of motion segments to include is controversial. Multi-level instrumentation techniques both in distraction and compression have been used as well as shorter constructs, particularly in the lumbar spine. We addressed the efficacy of single motion-segment fixation by evaluating the radiographic and functional results of this treatment technique.

Methods: All patients diagnosed with a FDI were prospectively identified over a 48 month period. Non-operatively treated fractures were excluded. Other spine fractures were excluded. Demographics, comorbidity, neurological status, operative details and complications were recorded. Radiographic reviewers were blinded to the functional outcome of the patient and the time of follow-up. The Oswestry Functional Assessment Questionnaire was administered by mail.

Results: Twenty-one eligible patients were identified. A significant (p< 0.0001) correction of deformity was achieved, from a mean preoperative kyphosis of 10.1 degrees to a mean postoperative lordosis of 0.9 degrees. No loss of correction occurred. The mean Oswestry score was 11.5, with 88% of patients having minimal disability. One patient died from unrelated morbidity.

Conclusions: Hoshikawa etal showed in vitro how compression forces alone can create FDI. Compression without flexion causes burst fractures. With moderate flexion there is FDI with anterior body compression. With increasing flexion FDI becomes entirely distractive. As the forces are concentrated at a single point, reconstruction only requires that this location be addressed. As all FDI are created by the same mechanism, regardless of structures injured only short segment fixation is required.

We have demonstrated in FDI, single level fixation is biomechanically sound. Multilevel instrumentation creates loss of adjacent level motion segments. This is not necessary. The absence of a control group precludes absolute conclusions. Nonetheless most patients reported minimal disability related to their back and had excellent radiological outcomes. This study demonstrates that posterior reduction and stabilization of a single motion-segment for FDI can adequately stabilize the spine and lead to excellent functional outcomes.