The Orthopaedic Digest

Wednesday, 8 May 2019

Acute Cervical Spine Injuries

DR KS Dhillon

Introduction

In patients with blunt trauma, cervical spine injuries are not uncommon. The most commonly involved vertebra is C2 followed by the C6 and C7 vertebra. The mortality rates from cervical spine injuries can be high because of high rates of spinal cord injury. Motor vehicles accident is the most common cause followed by falls from a height. Broadly, cervical spine injuries are classified into upper cervical and lower cervical spine injuries. The mainstay of diagnosis of cervical spine injuries are x rays and CT scan of the cervical spine. Treatment of injuries to the cervical remains a challenge. There is a dearth of literature on the long term outcome of management of cervical spine injuries.

Epidemiology and mechanism of injury

Cervical spine injuries are not uncommon in patients with blunt trauma. Goldberg et al [1] reported a 2.4% incidence of cervical spine injury in patients with blunt trauma and Hasler et al [2] reported a 2.3% incidence of cervical fractures/dislocations in patients with major blunt trauma.

The Goldberg et al [1] study showed that the C2 vertebra was injured in 24% of the patients with cervical injuries (most common). The second most commonly fractured vertebrae were the C6 and C7 vertebrae with a combined incidence of 39.3% of all cervical injuries. The vertebral body was the most common site of fracture. About one third of the injuries were considered clinically insignificant.
Cervical spine injuries constitute between 19% and 51% of all spinal injuries [3,4]. The incidence of cervical spine injuries peak between the ages of 20 to 45 years and 70 to 80 years [5]. The incidence of cervical spine injuries increase with age and male gender and age older than 64 years are risk factors [5]. The mortality rates for cervical spine injuries is the highest as compared to injuries in other parts of the spine because cervical spine injuries have a higher rate of cord injury [6].

The most common cause for the cervical spine injury is motor vehicle accidents which accounts for about half of the injuries. Falls from a height of less than 2 meters account for 20% of all injuries and sports injuries also play an important role in these injuries [2].

Classification of upper cervical spine injuries

The anatomical difference allows classification of cervical spine injuries into two i.e the upper cervical spine (occiput to C2) and the lower cervical spine (C3 to C7).

Classification of upper cervical spine injuries

Fractures of the upper cervical spine include fractures of the occipital condyle and fracture dislocations of C1 and C2 including the odontoid process.
Fractures of the occipital condyles are rare and are often classified according to a classification by Anderson and Montesano [7].They differentiated occipital condyle fractures into three types:

Type 1: Impression fractures of the occipital condyle (usually stable);

Type 2: Skull base fracture extending into the occipital condyle (usually stable);

Type 3: Avulsion fracture of the occipital attachment of the Alar ligament (potentially unstable).

Several classification systems are available for classification of C1 (Atlas ) fractures. The commonly used ones include the Jefferson classification [8], and the Gehweiler classification [9].

According to the Jefferson classification there are 4 types of fractures of the Atlas:
Type 1 = Fracture of the posterior arch alone
Type 2 = Fracture of the anterior arch alone
Type 3 = Fracture of both the posterior and anterior arches (also known as a burst or Jefferson's fracture)
Type 4 = Fracture of the lateral mass or masses of C1

The Gehweiler classification has five sub-groups of atlas fractures :
Type 1: Isolated fracture of the anterior arch
Type 2: Isolated (usually bilateral) fracture of the posterior arch
Type 3: Fracture of the anterior and posterior arch of the atlas (Jefferson fracture’).
Type 3A: Stable injuries with intact transverse atlantal ligament
Type 4: Fractures of the lateral mass
Type 5: Isolated fractures of the C1 transverse process.

The Odontoid fractures are usually classified according to a classification by Anderson/D’Alonzo [10]. There are 3 types of odontoid fractures:
Type 1: Fracture of the tip of the odontoid peg (rare)
Type 2: Fracture through the base of the odontoid peg (usually unstable) Type 3: Fracture through the base of the odontoid peg which runs in a u- or v-shape through the body of the axis (usually stable).

The commonly used classification for fractures of axis is the one by Effendi et al.[11] which was later modified by Lewine and Edwards [12]. The modified classification has five types.

Type I: Fracture of the pedicles, intervertebral disc C2/3 is intact, dislocation ≤3mm without angulation
Type IA: Fracture lines on each side are not parallel and the fracture line may involve foramen transversarium on one side
Type II: Fracture of the pedicles with more than 3mm dislocation and/or angulation with involvement of the C2/3 disc
Type IIA: Oblique fracture - anterior-inferior to posterior-superior with more angulation and some subluxation
Type III: Type II with C2/3 vertebral joints luxation. The posterior arch is free floating.
A locked C2-C3 facet joint constitutes a type III lesion.

Atlanto-Occipital dislocations or dissociations (AOD) are severe injuries with high fatality rates. The commonly used classification for these injuries is the one by Traynelis. The Traynelis classification [13] divides AOD into 3 types:
Type I: Anterior displacement of the occiput relative to the atlas
Type II: Distraction of the occiput from the atlas
Type III: Posterior displacement of the occiput relative to the atlas.

Powers’ ratio [14] is often used to diagnose anterior dislocation injuries. It compares measurements between the skull base and C1. The distance from the basion to the midpoint of the anterior cortex of the posterior arch of C1 is measured (X). The distance from the opisthion to the midpoint of the posterior cortex of the anterior arch of C1 is measured (Y). If X/Y exceeds 1, then AOD is suspected. Normal values are usually less than 0.9.

Classification of Lower cervical spine fractures

The widely used classification for lower cervical spine injuries is the one by the AO group. It divides lower cervical spine injuries into 3 types i.e type A, B, C based on the trauma mechanism.

A: compression
B: distraction
C: rotation

Type A compression injuries are further subdivided into type A.1 = impaction; A.2 = split; A.3 = burst.
Type B distraction injuries are further subdivided into B.1 = posterior distraction with vertebral body intact; B.2 = posterior distraction + fracture of the vertebral body; B.3 = anterior distraction + hyperextension.
Type C rotation injuries are subdivided into C.1 = unilateral facet fracture-dislocation; C.2 = unilateral facet dislocation; C.3 = rotational shear injury of the joint mass.
To remedy a lack of consensus on classification of lower cervical spine injuries the Subaxial Injury Classification (SLIC) Scale was created (15).This classification takes into account morphology; status of the disco-ligamentous complex and neurological assessment.

Table 1. Subaxial Injury Classification (SLIC) scale.

Points
Morphology
No abnormality 0
Compression + burst 1 + 1 = 2
Distraction (e.g., facet perch or hyperextension) 3
Rotation or translation (e.g., facet dislocation, unstable teardrop,
or advanced-stage flexion-compression injury) 4

Disc-ligamentous complex
Intact 0
Indeterminate (e.g., isolated interspinous widening or
MRI signal change only) 1
Disrupted (e.g., widening of the anterior disk space or facet perch
or dislocation) 2

Neurological status
Intact 0
Root injury 1
Complete cord injury 2
Incomplete cord injury 3
Continuous cord compression (neuro-modifier in the setting
of a neurological deficit) + 1

Based on the above parameters, scores are assigned to each injury. Patients with a score lower than 4 will need nonsurgical treatment and patients with higher then 4 will require surgical treatment. Patients with a score of 4 can be treated surgically or nonsurgically depending on the experience of the surgeon.

Radiographic Assessment

AANS/CNS Joint Guidelines recommend the following in the guidelines for radiographic assessment of patients with cervical spine injuries [15].

Awake, Asymptomatic Patient
Level 1 evidence
• In an asymptomatic patient who is awake and has no neck pain and
tenderness and in whom the neurological examination is normal and
the range of cervical movement is normal, radiological assessment is
not recommended
• Discontinuance of cervical immobilization is recommended in these
patients without cervical spine imaging.

2. Awake, Symptomatic Patient
Level I evidence
• In a symptomatic awake patient, high-quality computed tomography
(CT) imaging of the cervical spine is recommended.
• When high-quality CT imaging is available, routine cervical spine
radiographs are not recommended.
• In situations where high-quality CT imaging is not available, 3-view
cervical spine radiographs are obtained (anteroposterior, lateral, and
odontoid views). The radiographs can be supplemented with CT (when
it becomes available) if necessary for better visualization of suspicious
Areas.

3. Obtunded or Unevaluable Patient
Level I evidence
• In a obtunded or unevaluable patient, high-quality computed
tomography (CT) imaging of the cervical spine is recommended.
• When high-quality CT imaging is available, routine cervical spine
radiographs are not recommended.
• In situations where high-quality CT imaging is not available, 3-view
cervical spine radiographs are obtained (anteroposterior, lateral, and
odontoid views). The radiographs can be supplemented with CT (when
it becomes available) if necessary for better visualization of suspicious
areas

Important radiographic measures

1.Cranio-cervical interval (CCI)

Although there are several radiographic parameters available for occipital-cervical instability, the one with the best sensitivity and specificity is the revised CCI (rCCI), developed by Pang et al [17]. The distance between the occipital condyle and the facet joint surface of the atlas lateral mass is measured in the sagittal plane and if the value exceeds 2.5 mm, an unstable lesion is most likely present.

2.The anterior atlanto-dental-interval (aADI)
The aADI detects translatory instability due to lesions of the transverse atlantoaxial ligament. The distance between the anterior cortex of the odontoid peg and the posterior cortex of the anterior ring of the atlas is measured. In adults, any value greater than 3 mm is regarded as abnormal.

3.Facet joint overlap
Overlap of facet joint surfaces of two neighbouring articular processes in the lower cervical spine, can indicate the presences of instability in the facet joints. An overlap of less than 50% of the length of the articular process indicates instability.

4.Prevertebral soft tissue

Prevertebral soft-tissue swelling is an indirect sign of cervical spine injury. The mnemonic ‘six at two, twenty-two at six’ has been widely used to remember normal values for prevertebral soft-tissue thickness at the second and sixth cervical vertebra. The normal thickness of the prevertebral soft tissue in front of C2 is 6mm and in front of C6 is 22mm. The prevertebral soft-tissue thickness has good specificity but very low sensitivity [18].

Management of cervical spine injuries

Steroid protocol

Methylprednisolone sodium succinate is often administered if a patient with cervical spine injury presents within 8 hours of injury. A bolus dose of 30mg per kg is administered over 15 minutes and an infusion of 5.4mg per kg per hour is maintained over the next 23 hours. This regime has been shown to improve neurologic outcome up to one year post-injury.

In patients whom the steroid cannot be administered within 8 hours methylprednisolone therapy can be given for an additional 24 hours (a total of 48 hours). This therapy has been shown to provide additional improvement in motor neurologic function and functional status [19].

A Cochrane database systematic review by Bracken [19] showed that high-dose methylprednisolone steroid therapy is the only pharmacologic therapy which has been shown to have efficacy in a phase three randomized trial when administered within eight hours of injury. Another trial found additional benefit of extending the maintenance dose from 24 to 48 hours, if there has been a delay in start of treatment beyond 8 hours.

Literature review did not show evidence of a significant increase in complications or mortality from the 23 or 48 hour therapy.

Cervical spine injury treatment and management principles

The main principles of treatment include decompression of compressed neurological structures, restoration of vertebral column integrity, prevention and management of complications, and facilitation of rehabilitation [20].

Many patients with cervical spine injuries can be treated nonoperatively. Options for conservative treatment include use of a cervical orthosis or rigid stabilisation with a halo jacket.

In patients with displaced cervical spine injury a closed reduction is carried out except in patients Hangman’s type, IIA fracture. In the Hangman’s type, IIA fractures, traction can further displace the fracture and increase the risk of spinal cord injury.

It is safe to treat, displaced Jefferson fracture, Hangman’s fracture, type II/type III odontoid peg fracture, displaced subaxial fracture and subaxial subluxations and dislocations, by traction [20].

Lee et al [21] carried out a study involving 210 patients with unilateral and bilateral facet dislocations. They found that rapid traction under sedation using weights upto 150 pounds was safer than carrying out manipulation under anesthesia. They also found that early reduction of the dislocation in patients with neurological deficit gave them the best chance of neurological recovery.

Surgical management

Surgery is usually indicated in patients when a close reduction has failed, in patients with unstable injuries, when there is bilateral facet dislocation of more than 25% or 11°. Progressive neurological deterioration would be another indication for surgery. Kyphosis of 30° or more or loss of vertebral height of more than 50% is often associated with a high incidence of late complications, and this situation may warrant surgical intervention. Late instability and severe post traumatic kyphosis may warrant surgical intervention [20].

In patients with partial neurological injury early surgical intervention is usually recommended. There is some evidence that early surgical intervention (less than 24 hours) is safe and effective, and even in patients where delayed decompression was carried out there can be some neurological recovery [22,23].

Some have claimed that 70% of patients with partial spinal cord injury improve one grade or more (American Spinal Injuries Association, International Medical Society of Paraplegia grades) if the surgery is carried in less than 6 hours after the injury [24]. When surgery is carried out after 6 hours only 12% of the patients show improvement. In patients with a complete spinal cord injury the chances of neurological recovery is poor.

Decompression and/or stabilised of the cervical spine can be carried out via the anterior, posterior or a combination of both approaches, depending on the type of injury.The clinical success rates are higher with the anterior approach though the anterior approach is biomechanically inferior to the posterior approach [20].

Long term outcome of cervical spine injury treatment

There is a dearth of literature on the long term outcome of management of cervical spine injuries. The largest study with a long term follow up is the one by Fredø et al [25]. They followed up 256 patients with subaxial cervical spine injuries who were treated surgically. The mean follow-up period was 3.1 years with range of 0.5–9.0 years. None of their patients had neurological deterioration after the surgery.

In patients who were operated within 24 hours, 48.8% showed improvement of their neurological grades whereas in patients operated after 24 hours 53.1% showed improvement in their neurological grades. The improvement in AIS (American Spinal Injury Association impairment scale) grades between the two groups were not significantly different (p = 0.442). Of the patients with preoperative radiculopathy 11 % of the patients continued to have radicular symptoms. There were four patients who developed radiculopathy after surgery, three of these patients were asymptomatic at the follow-up.

Neck pain was assessed using the Visual Analog Scale (VAS). They found that the median VAS score for neck pain was 1 (range 0–10). Eighty percent of the patients had VAS scores ≤3, 15 % had VAS scores 4–6, and 5 % had VAS scores ≥7. There was no significant association between the surgical approach and neck pain [25].

They found that 26% of the patients had no neck stiffness, 63% had mild neck stiffness and 11% had severe neck stiffness. Neck stiffness was more common in patients who had fusion with posterior screw fixation.

Six percent of patients sustained hoarseness and 9% developed dysphagia after surgery.
Of the 256 patients who were followed up with cervical CT scans, 98.4 % had a stable fusion, 0.4 % had a secondary loss of alignment, and in 1.2 % of the patients there was loosening or fracture of their fixation device [25].
In this study the surgical mortality (death within 30 days after surgery) was 2.3 %.

Conclusion

Cervical spine injuries are not uncommon in patients with blunt trauma.
Cervical spine injuries constitute between 19% and 51% of all spinal injuries. Mortality rates for cervical spine injuries is the highest as compared to injuries in other parts of the spine because cervical spine injuries have a higher cord injury rates. Broadly, cervical spine injuries can be divided into two, namely, the upper cervical spine (occiput to C2) injuries and the lower cervical spine (C3 to C7) injuries.

There are several classifications available for both the upper and lower cervical spine injuries which help in the management of these patients. Radiological examination, including X rays and CT scans, is the main diagnostic tool used in patients with cervical spine injury.

Patients who present within 8 hours are given 23 hours of steroid therapy and those who present later can be given 48 hours therapy. Steroid therapy has been shown to improve the neurological outcome.
The main principles of treatment include decompression of compressed neurological structures, restoration of vertebral column integrity, prevention and management of complications, and facilitation of rehabilitation. Many patients with cervical spine injuries can be treated nonoperatively.
Surgery would be indicated in patients when a close reduction has failed, in patients with unstable injuries and when there is bilateral facet dislocation of more than 25% or 11°. Progressive neurological deterioration and kyphosis of 30° or more or loss of vertebral height of more than 50% may be other indications for surgical intervention.

Despite the presences of a lot of literature on cervical spine injuries, there is a dearth of literature on the long term outcome of management of cervical spine injuries.

References

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Hasler RM, Exadaktylos AK, Bouamra O, Benneker LM, Clancy M, Sieber R, Zimmermann H, Lecky F. Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study. J Trauma Acute Care Surg. 2012 Apr;72(4):975-81.
Lenehan B , Boran S , Street J et al. Demographics of acute admissions to a National Spinal Injuries Unit. Eur Spine J 2009; 18:938–942.
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Lowery DW , Wald MM , Browne BJet al. Epidemiology of cervical spine injury victims. Ann Emerg Med 2001;38:12-16.
Varma A , Hill EG , Nicholas J , Selassie A . Predictors of early mortality after traumatic spinal cord injury: a population-based study. Spine 2010;35:778-783.
Anderson PA , Montesano PX . Morphology and treatment of occipital condyle fractures. Spine 1988;13:731-736.
Jefferson G . Fracture of the atlas vertebra. Report of four cases, and a review of those previously recorded. Br J Surg 1919;7:407-422.
Gehweiler JA , Osborne RL , Becker RF . The radiology of vertebral trauma. Philadelphia, PA: W. B. Saunders Company; 1980.
Anderson LD , D’Alonzo RT . Fractures of the odontoid process of the axis. J Bone Joint Surg [Am] 1974;56-A:1663-1674.
Effendi B, Roy D, Cornish B, Dussault RG, Laurin CA. Fractures of the ring of the axis: a classification based on the analysis of 131 cases. J Bone Joint Surg Br. 1981;63:319–327.
Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am. 1985 Feb; 67(2):217-26.
Traynelis VC, Marano GD, Dunker RO, Kaufman HH. Traumatic atlanto-occipital dislocation. Case report. J Neurosurg. 1986;65:863–870.
Powers B, Miller MD, Kramer RS, Martinez S, Gehweiler JA. Traumatic anterior atlanto-occipital dislocation. Neurosurgery. 1979;4:12–17.
Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, et al. The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system. Spine (Phila Pa 1976) 2007;32(23):2620–9.
Ryken et al. Radiographic Assessment. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries at https://www.cns.org/sites/default/files/guideline-chapter-pdf/Radiographic_Assessment.9.pdf.
Pang D, Nemzek WR, Zovickian J. Atlanto-occipital dislocation--part 2: The clinical use of (occipital) condyle-C1 interval, comparison with other diagnostic methods, and the manifestation, management, and outcome of atlanto-occipital dislocation in children. Neurosurgery. 2007 Nov;61(5):995-1015.
Hiratzka JR, Yoo JU, Ko J-W, et al. Traditional threshold for retropharyngeal soft-tissue swelling is poorly sensitive for the detection of cervical spine injury on computed tomography in adult trauma patients. Spine 2013;38:E211-E216.
Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 2012 Jan 18;1:CD001046.
O'Dowd JK. Basic principles of management for cervical spine trauma. Eur Spine J. 2009;19 Suppl 1(Suppl 1):S18–S22. doi:10.1007/s00586-009-1118-2.
Lee AS, MacLean JC, Newton DA. Rapid traction for reduction of cervical spine dislocations. J Bone Joint Surg Br. 1994 May;76(3):352-6.
La Rosa G, Conti A, Cardali S, Cacciola F, Tomasello F. Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach. Spinal Cord 2004;42:503-12.
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Fehlings M, Aarabi B, Dvorak M, et al. (2008) A prospective multicenter trial to evaluate the role and timing of decompression in patients with cervical spinal cord injury: initial one-year results of the STASCIS study. Paper presented at the AANS meeting in Chicago.
Fredø HL, Rizvi SAM, Rezai M, Rønning P, Lied B and Helseth E. Complications and long-term outcomes after open surgery for traumatic subaxial cervical spine fractures: a consecutive series of 303 patients. BMC Surgery (2016) 16:56

Tuesday, 16 April 2019

Outcome of Treatment of Traumatic Thoracolumbar Spine Fractures

Dr. KS Dhillon

Introduction

Fractures of the thoracolumbar spine are relatively common and represent about 65% of all traumatic spinal fractures. Thoracolumbar fractures are more common in men, and the peak incidence is seen between the ages of 20 and 40 years.

Fifty percent of thoracolumbar fractures are unstable fractures. These injuries can produce permanent disability resulting in significant social and economic burden on society. Neurological injury can be present in about 20% to 36% of the patients with thoracolumbar fractures. Neurological deficit can result in severe physical disability. It is usually not possible to predict neurological recovery in patients with traumatic spinal cord injuries because recovery depends on several preoperative prognostic factors.

The outcome of treatment of thoracolumbar fractures without neurological deficit is generally good on long term follow up. Despite technological advances in the treatment of spinal fractures, outcomes of surgery, however, remains unpredictable.

Classification of thoracolumbar fractures

There are several classification systems for thoracolumbar fractures of which the most commonly used one is that by Denis.The Denis classification divides the spine into three columns, the anterior, middle and posterior column. The anterior column consists of the two anterior third of the vertebral body and discs and the anterior longitudinal ligament, the middle column consist of the posterior third of the vertebral body and disc as well as the posterior vertebral body wall and the posterior longitudinal ligament and the posterior column consists of the pedicles, laminae, facet joints and the posterior ligamentous complex (PCL) [1]. This classification is only moderately reliable in determining clinical degree of stability. Instability is said to be present if two or more columns are disrupted.

The Denis classification has been criticized for being too simplistic that it fails to identify ligamentous injuries which can lead to occult, progressive instability.

The Spine Trauma Study Group have introduced a new classification system called the thoracolumbar injury classification and severity score (TLICS). This classification system is based on injury morphology, posterior ligamentous complex integrity and the neurologic status of the patient [2].
The injury morphology can be identified from the imaging studies. There are 3 types of injuries, compression injuries (which can produce a compression fracture or a burst fracture), translational/rotational injuries, and lastly the distraction injuries. The compression fracture is allotted 1 point, a burst fracture 2 points, translational and rotational injuries 3 points and distraction injuries 4 points (table 1).

TLICS scoring

Parameter Points
Morphology
Compression fracture 1
Burst fracture 2
Translational/rotational 3
Distraction 4

Neurologic involvement
Intact 0
Nerve root 2
Cord, conus medullaris
Incomplete 3
Complete 2
Cauda equina 3

Posterior ligamentous complex
Intact 0
Injury suspected/indeterminate 2
Injured 3

Table 1. TLICS scoring system [2]

There are five categories of neurologic injury, namely intact neurologic status, nerve root injury, complete spinal cord injury, incomplete spinal cord injury, and cauda equina syndrome. Patients with intact neurologic status are alloted zero points, nerve root injury or complete spinal cord injury are allotted two points and patients with an incomplete spinal cord injury or cauda equina syndrome are allotted three points. In the last group higher points are allotted because surgical decompression in these patients can be very useful.

For the posterior ligamentous complex there are 3 categories. The first where the PCL is intact (0 points), second where injury is suspected (2 points and the third where the PCL is disrupted (3 points). A palpable interspinous gap and interspinous widening on x rays would be present when the PCL is completely disrupted.

The allotted points in the three categories are added up to get the total score which will help in decision making as to whether or not surgery should be carried out to treat the injury. Patients with 3 or less points are treated nonoperatively and patients with 5 points or more are treated operatively. Patients with a total score of 4 belong to an indistinct group, where either nonoperative or operative treatment can be considered (Table 2).

Management as per TLICS score

Management Points
Nonoperative 0–3
Nonoperative or operative 4
Operative ≥5

Table 2. Management as per TLICS score [2]

Outcome of treatment of thoracolumbar fractures

Abudou et al [3] carried out a Cochrane systematic review of literature upto September 2012 to compare the outcomes of surgical with non-surgical treatment of patients with thoracolumbar burst fractures who had no neurological deficit. They were only able to find two suitable studies which reported the outcome in 79 patients who were followed up for two years or more. Both studies were judged to have unclear risk of selection bias and a high risk of performance and detection biases because of lack of blinding.

They found that there is insufficient evidence in literature to conclude ‘whether surgical or non-surgical treatment yields superior pain and functional outcomes for people with thoracolumbar burst fractures without neurological deficit’ [3]. Surgery can be associated with early complications and need for repeat surgery. Surgical treatment is more costly than non-surgical treatment.

Gnanenthiran et al [4] carried out a meta-analysis to compare pain (VAS) and function (Roland Morris Disability Questionnaire) in patients who had thoracolumbar burst fracture with no neurologic deficit and were treated surgically or non-surgically. Secondary outcomes measured included ‘return to work, radiographic progression of kyphosis, radiographic progression of spinal canal stenosis, complications, cost, and length of hospitalization’[4]. They found that there was no differences in pain, RMDQ score, kyphosis, and return to work rates between the two groups. There was better radiographic correction in the surgical group but surgical treatment was associated with higher complication rate and higher cost of treatment.

The authors concluded that there was insufficient evidence in literature to support the superiority of surgical treatment over non-surgical treatment in the treatment of patients with thoracolumbar burst fractures with no neurologic deficit.

Bakhsheshian et al [5] did a systematic review of literature over a 20 years period to assess the outcome of nonoperative management of traumatic thoracolumbar burst fractures. There wear 45 studies which met their inclusion criteria. Of these 45 studies,16 studies investigated techniques of conservative treatment, 20 studies compared surgical to non-surgical management, and 9 papers investigated the prognosis of non-surgical treatment.

They found 9 high-level studies (Levels I–II) which investigated the non-surgical management of burst thoracolumbar fractures.They found that the outcome of treatment in neurologically intact patients was the same irrespective of the technique used for conservative treatment. No one technique was found to be superior to another.

There was a high level of evidence which demonstrated that the functional outcomes with non-surgical management when compared with surgical management was the same in patients who had no neurological deficit. There was high level evidence to show that neurological deficit is not an absolute contraindication for conservative treatment.

Scheer et al [6] carried out a systematic review of literature, including publications over a 20 years period, to assess the outcome of surgical treatment of thoracolumbar burst fractures. Twenty three level 1 and level 2 studies met their inclusion criteria.

They found that there was high level evidence for short or long-segment posterior pedicle instrumentation of the spine without fusion. Long-segment pedicle fIxation provided better correction as compared to short segment fixation. The Low Back Outcome Scores (LBOS) however were similar. Long constructs provided more rigidity but it reduced patient mobility which affected patients quality of life.

Spinal fusion is not necessary in addition to spinal instrumentation. Fusion does not improve clinical or radiological outcome after posterior instrumentation. Fusion can, however, increase the operative time and risk of infection. Open approaches to spine surgery can be associated with higher morbidity. High level evidence shows that the thoracolumbar muscle attachments are best preserved and percutaneous as well as paraspinal approaches are useful for the treatment of thoracolumbar burst fractures.
There is level 2 evidence to show that the radiographic, clinical, and functional outcomes are similar irrespective of whether an anterior, posterior, or combined approach is used for instrumentation. The complication rates are higher with the anterior and combined approaches as compared to the posterior approach. The cost of treatment was higher with the anterior approach as compared to the posterior approach.

Moller et al [7] studied the outcome of nonoperatively treated burst fractures of the thoracic and lumbar spine in adults at an average follow up of 27 years (range 23 to 41 years). Their study included 16 men with an average age of 31 years and 11 women with an average age of 40 years.
There were 4 Denis type A burst fractures, 18 Denis type B, 1 Denis type C, and 4 Denis type E fractures. Seven patients had neurological deficits.

At follow-up, 21 patients reported no or minimal back pain or disability with an Oswestry mean score of 4 (range 0-16). Six patients, three of who were classified Frankel D at baseline reported moderate or severe disability with an Oswestry mean score of 39 (range, 26-54). Of the 27 patients, 6 were classified as Frankel D, and 21 were classified as Frankel E. They found that the local kyphosis had increased by a mean of 3 degrees. The disc height adjacent to the fractured vertebra remained unchanged at follow up.

They concluded that the long term outcome, of nonoperative treatment of burst fractures of the thoracolumbar spine in adults with minor or no neurological deficit, is predominantly favorable and that there appears to be no increase in risk for disc height reduction in the adjacent discs on long term follow up.

Moller et al [8] studied the long term outcome of treatment of thoracolumbar vertebral fractures in late adolescence. Eighteen boys and 5 girls with thoracolumbar fractures were followed up after 27 to 47 years with subjective, objective and radiological evaluation. Fourteen patients had a one-column compression fracture, one had a Denis type A, six a Denis type B, one a Denis type D and one patient had a Chance fracture. At baseline one had a partial paresis of one leg and another one developed a transient paraparesis during the first week. All the patients were treated non-surgically. At the last follow-up, 18 patients had no complaints, 5 had occasional back pain. Twenty were classified as Frankel E and 3 were classified as Frankel D. The radiographic vertebral height of the fractured vertebra remained unchanged during the study period.

They concluded that patients in late adolescence who are treated conservatively for thoracolumbar fractures with minor or no neurological deficit have a favourable long-term outcome.

The post traumatic kyphosis in the fractured region following thoracolumbar fractures in children below 13 years at the time of injury can decrease with time. Karlsson et al [9] did a study involving 12 boys and 12 girls, aged 7-16 years who sustained thoracolumbar fractures which were treated conservatively. The follow up period was between 27 to 47 years. They found that in 8 individuals (33%), all aged 13 or less at the time of the fracture, there was a decrease of post traumatic kyphosis at the last follow up. This would mean that remodelling of the vertebrae is possible in young children. No increase in degeneration of the adjacent disc was observed in this study.

Outcome of treatment in patients with neurological deficit

Literature on the long term outcome of treatment of patients with thoracolumbar fractures associated with neurological deficit is sparse.

Dobran et al [10] carried out a retrospective analysis of 69 patients who were treated operatively for traumatic spinal cord injury. The patients had posterior stabilization of the spine performed within 24 hours of the the trauma. Surgery was indicated in patients with neurological deficit, severe spinal deformity with canal encroachment of more than 50%, vertebral body wedging of more than 60%, kyphosis of more than 25° and when there was spinal instability.

At one year follow up, 72.4% of the patients with neurological deficit show an improvement in neurological function and no patients deteriorated after the surgery.

The neurological improvement rates were 88.46% in patients with lumbar injuries, 45.45% in thoracic injuries and 66.6% in patients with thoracolumbar injuries.

In patients with thoracolumbar spinal cord injuries, 72.4% of the patients neurologically improved one or more ASIA (American Spinal Injury Association) level after the surgery compared to the neurological status on admission.

Marré et al [11] carried out a retrospective review of 51 patients who had thoracic fractures and were treated by surgery. Of the 51 patients who had surgery, 6 had incomplete neurological deficit and 22 had a complete lesion on admission.

Three of the four patients who were ASIA B at presentation improved one ASIA grade at one year follow up. Two patients with ASIA D made full recovery. Five of the 6 patients (83.3%) who had an incomplete cord injury demonstrated neurological recovery during their follow-up.

The study showed that in none of the patients with ASIA A there was improvement in their neurological status. There was no deterioration of neurological status in any of the patients.
Verlaan et al [12] carried out a systematic review of the literature, to evaluate surgical treatment of traumatic thoracic and lumbar spine fractures. They found a 132 full-text papers from 1970 until 2001. The majority of the papers were retrospective case-series. The total number of patients in these papers was 5,748 patients. There were five surgical techniques that were used for treatment of these patients. This included posterior short-segment, posterior long-segment, anterior and combined anterior with posterior (AP) techniques.

They assessed the neurological, radiologic, and functional outcome and complications in this group of patients. They found that partial neurological deficits had a potential to resolve irrespective of the type of surgical treatment provided. Surprisingly, none of the five techniques used was able to maintain the corrected kyphosis angle. The functional outcome after surgery appears to be better than what is usually assumed by most people. They found that complications after surgery were uncommon.

Conclusion

Treatment of traumatic thoracolumbar burst fractures remains a challenge. There appears to be no consensus as to what is the best techniques for operative and nonoperative treatment of these fractures. The main aim of treatment is to mobilize the patient early and to obtain a stable spine with maximum mobility as well as to obtain the best possible neurological outcome. In patients who have no neurological deficit the optimal treatment is nonsurgical. There is high level of evidence to show that the outcome of conservative treatment in patients with no neurology is the same as those with surgical treatment without the complications associated with surgery. The cost of nonsurgical treatment is also lower then surgical treatment.

The evidence in support of the optimal treatment for patients with neurological deficit, however, remains unclear. When clinical and radiological assessment shows that the patient requires surgery, there is no consensus on the technique to be used for spinal stabilization. There, however, is some evidence in literature to show that short- or long-segment pedicle instrumentation without fusion is preferable. The percutaneous and paraspinal approaches have been found to be less invasive.
The long term outcome of conservative treatment of burst fractures of the thoracolumbar spine in adolescents and adult with no or minor neurological deficit is generally favourable.

There are several surgical techniques available for the treatment of unstable spine fractures. Studies show that there is no one technique which is superior to another. The anterior and combined approaches were associated with more complications. Partial neurological deficits after spinal injuries have a potential to resolve but ASIA A type of complete paralysis usually has no potential for recovery.

References

Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817–831.
Vaccaro AR, Zeiller SC, Hulbert RJ, Anderson PA, Harris M, Hedlund R, et al. The thoracolumbar injury severity score: a proposed treatment algorithm. J Spinal Disord Tech. 2005;18:209–15.
Abudou M, Chen X, Kong X, Wu T. Surgical versus non-surgical treatment for thoracolumbar burst fractures without neurological deficit.Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD005079. DOI: 10.1002/14651858.CD005079.pub3.
Gnanenthiran SR, Adie S, Harris IA. Nonoperative versus operative treatment for thoracolumbar burst fractures without neurologic deficit: a meta-analysis. Clin Orthop Relat Res. 2011;470(2):567–577. doi:10.1007/s11999-011-2157-7.
Bakhsheshian J et al. Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of nonoperative management. Neurosurg Focus . 2014; Volume 37 (1): 1-8.
Scheer JK, Bakhsheshian J, Fakurnejad S et al. Evidence-Based Medicine of Traumatic Thoracolumbar Burst Fractures:A Systematic Review of Operative Management across 20 Years. Global Spine J 2015;5:73.
Moller A, Hasserius R, Redlund-Johnell I, Ohlin A, Karlsson MK. Nonoperatively treated burst fractures of the thoracic and lumbar spine in adults: a 23- to 41-year follow-up. Spine J. 2007 Nov-Dec;7(6):701-7.
Moller A, Hasserius R, Besjakov J, Ohlin A, and Karlsson M. Vertebral fractures in late adolescence: a 27 to 47-year follow-up. Eur Spine J. 2006 Aug; 15(8): 1247–1254.
Karlsson MK, Moller A, Hasserius R, Besjakov J, Karlsson C, Ohlin A. A modeling capacity of vertebral fractures exists during growth: an up-to-47-year follow-up. Spine (Phila Pa 1976). 2003 Sep 15;28(18):2087-92.
Dobran M, Iacoangeli M, Di Somma LG M, Rienzo AD, Colasanti R, Niccolò Nocchi, Alvaro L, Moriconi E, Nasi D, Scerrati M. Neurological outcome in a series of 58 patients operated for traumatic thoracolumbar spinal cord injuries. Surg Neurol Int 28-Aug-2014;5.
Marré B, Ballesteros V, Martínez C, et al. Thoracic spine fractures: injury profile and outcomes of a surgically treated cohort. Eur Spine J. 2011;20(9):1427–1433. doi:10.1007/s00586-011-1698-5.
Verlaan JJ, Diekerhof CH, Buskens E, van der Tweel I, Verbout AJ, Dhert WJ, Oner FC. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine (Phila Pa 1976). 2004 Apr 1;29(7):803-14.

Wednesday, 3 April 2019

Meritocracy -- A Myth or A Paradox?

Dr. KS Dhillon

Introduction

Meritocracy is a term which was first introduced by Michael Young in his 1958 dystopian satirical book ‘The Rise of the Meritocracy’ [1]. Young introduced the formula that “IQ + effort = merit”. The Merriam-Webster dictionary defines meritocracy as ‘a system in which the talented are chosen and moved ahead on the basis of their achievement’ [2].

There is a widespread belief that rewards in life such as university admissions, jobs, money, and power should be skill and effort based. This belief has made meritocracy a leading social ideal.
Many who believe in meritocracy are of the opinion that hereditary aristocracy based on birth should be cast aside to create a level playing field. Merit is the product of talent (IQ) plus determined effort (effort). Hence many believe that merit rather than luck determines success or failure. There are others who believe that this assumption is demonstrably false because talent and the capacity for determined effort depend to a large extent on one’s genetic endowments and upbringing. To have the required genetic endowments and upbringing is, most of the time, a matter of chance [3].

There are two sides to the issue of meritocracy, the objective, and subjective side. The objective side looks at whether social positions in society are distributed according to academic achievement since academic achievement is considered as an indicator of individual merit. The subjective side looks at whether people are convinced that the diplomas obtained by education are acquired through merit and that later in life the best-educated individuals get the best social positions.

Does meritocracy exist? Is it a myth?

This is a very important question considering that there is a shift to meritocratic employment strategies across the world. Many people believe that the world is meritocratic and they also believe that the world should be run meritocratically. A 2009 British Social Attitudes survey in the UK found that 84 percent of respondents were of the opinion that hard work is essential and very important if one has to get ahead in life [4]. Similarly, a survey by the Brookings Institute (USA) in 2016 found that 69 percent of Americans believed that people are rewarded for intelligence and skill.

The respondents in both UK and USA believed that factors, such as luck and having a wealthy background were less important. Similar thoughts are apparently popular around the world [3].
Many around the world believe that rewards in life such as university admissions, jobs, money, and power should be based on skill and effort rather than lottery of birth or hereditary aristocracy.
Intellectuals such as McManus, for example, believe that Britain is a meritocracy, with its social class related strongly to intelligence [5]. He also believes that intellectual ability is a major predictor of school examination results and hence entrance to universities.

Saunders [6] on the other hand believed that upward social mobility is due to one's ability rather than on formal qualifications alone. Brighter people he believes, tend to perform better in exams as well as in the labour market. He believed that one can work one's way out of a position in low social class if one is able and motivated enough.

Though the infrastructure for this upward mobility exits, there is not much such upward mobility from the working class to the middle class. The reason why the middle-class individuals can get their children into the same social class in society is because their children are equally motivated as them and the children of working class lack the ability and motivation to advance in society. Saunders beliefs offer ‘a social-Darwinian justification to social class inequalities and relative class mobility, whereby the ‘fittest’ and ablest get a better share of the resources available in a social system’ [7]. His understanding of meritocracy hence is compatible with a market-driven, competitive society.
Though there are different definitions of merit and irrespective of how one defines merit, the impact of merit on upward social mobility remains limited.

Though educational qualifications are important, they are not sufficient to help a person in securing access to a better social position in society [7]. This so-called ‘meritocratic failure’ is often attributed to the role the family plays in a given individuals life. Studies show that ‘parents income and cultural status’ is closely related to an individual's elite private school education and elite university education [7]. This type of education rather than merit help individuals land the highest paying jobs and high social positions in society.

Sadly in many societies equality of opportunities and education do not exist for meritocracy to work. Even if more opportunities were provided to working-class children through education, the structural and cultural inequalities will remain, preventing upward social mobility for these class of individuals [7].

Many believe that meritocracy, as defined by most people, is a myth. More people apparently advance in life due to unquantifiable and unpredictable random factors, such as relatives, friends, chance meetings, etc, rather than from the knowledge, IQ and the qualification that they possess [8]. Discrimination exists in most societies where privileged groups, privileged races and social elites such as the middle class, the whites, males and heterosexuals, progress upwards much more easily and faster than other groups or individuals [8].

Connections with people in high positions in government and private sector can ensure career progression and advancement in social status more than qualifications or intelligence can. Rich parents can buy entrance into elite schools and universities as well as secure jobs in elite professions, for their children, regardless of their innate intelligence [8].

The existence of meritocracy, therefore, appears to be a myth, although it is widely held that merit rather than luck ultimately determines success or failure. Some would go to the extent of saying merit itself is largely the result of luck. Genetic endowments and upbring provides the talent and grit needed for success in life. In essence, the concept of meritocracy, therefore, is something that can to a large extent be inherited and not earned over generations. Some have described meritocracy as a long-standing delusion of which we hear everyday and everywhere [9].

Notwithstanding the myth of meritocracy, meritocracy has been described as a paradox by others.

The Paradox of Meritocracy

Castilla and Benard [10] coined the phrase “paradox of meritocracy”. In an ideal meritocratic system every individual irrespective of their race, gender and class should have an equal opportunity to progress and advance in the society based on their individual merit and effort [10]. Many researchers believe that the system does work on the basis of merit [11,12,13].

Some believe that meritocracy has become the culture in most advanced capitalist countries and this culture provides fair and legitimate distribution of rewards in most organizations [14,15,16].
Despite the belief of many that the meritocracy system does exist and does work in most organizations, there are others who believe that inequalities exist at the workplace in organizations which have adopted merit-based programs [17].

Castilla and Benard [10] developed and tested a ‘theoretical argument that when an organizational culture promotes meritocracy (compared with when it does not), managers in that organization may ironically show greater bias in favor of men over equally performing women in translating employee performance evaluations into rewards and other key career outcomes’.

They conducted three experiments involving 445 participants who had managerial skills. They were asked to make recommendations for promotion, bonus, and job termination based on several employee profiles. They manipulated the gender of the employees who were being evaluated and they also manipulated the companies whose core values emphasized meritocracy in evaluations and compensation with that which did not. Their findings were consistent across all three studies. They found that in organizations which were labeled as meritocratic, the managerial individuals preferred male employees over equally qualified female employees. The males were given a larger monetary reward as compared to equally qualified female employees in meritocratic organization. In non-meritocratic organizations, no such discrimination was found.

The reason for this paradox is not clear but there are a couple of mechanisms which make it possible. One is the role of moral credentials. When an individual has established his moral credentials as a non-prejudiced person he is more prone to express prejudiced attitudes [18]. In organizations where there is a strong belief that the organization is meritocratic, the managers who also endorse this belief, tend to do moral credentialing which make bias more likely when dealing with their employees. The culture in these organizations convinces the managers to believe that they are unbiased since the are a meritocratic organization. This then prevents them from having insight into their own prejudices. When the managers start to believe that they are unbiased and fair, than they become convinced that their motivations will not be questioned and their actions will not be interpreted as prejudiced. In such situations, they feel less constrained by social norms and they allow their decisions to be influenced by stereotypes which leads to discrimination in the organization [10].

The other mechanism is the sense of personal objectivity. Uhlmann and Cohen [19] believe that personal objectivity dictates the extent to which an individual acts on his/her beliefs. This will also include stereotypical beliefs. Their work showed that when people feel objective, they become
more confident that their beliefs are correct and they are more likely to act on their beliefs. Hence, when people hold negative stereotypes about women at the workplace, they are likely to express these stereotypes in employment decisions.

Crandall and Eshleman [20] coined the term “justification-suppression model” (JSM) of prejudice. According to Crandall and Eshleman their JSM shows that there are several ‘social, cultural, cognitive, and developmental factors’ which create a variety of prejudices in people, including, ‘racial, ethnic, religious, sexual, patriotic, and so on’. These factors create so called "genuine" prejudices. These genuine prejudices are negative reactions which cannot be seen but are powerful and have strong motivational forces. Other forces such as social norms, personal standards, beliefs and values can suppress these prejudices. Suppressed prejudices can be expressed when liberated by beliefs, ideologies and attributions. Justification processes facilitates the expression of these prejudice, and ‘justification allows expression of prejudice without guilt or shame’. This leads to discrimination at the workplace [20].

Without doubt managers in a meritocratic organization believe that their decisions are impartial and they apply stereotypes in their employment decisions. The prejudices maybe racial, ethnic, religious, sexual or others. This paradox of meritocracy is real and exits in most so called meritocratic organizations.

Meritocracy in Malaysia

‘We hold these truths to be self–evident, that all men are created equal, that they are endowed by their Creator with certain inalienable rights,
that among these are life, liberty and the pursuit of happiness’.
- Thomas Jefferson

But in Malaysia, all are not created equal. Article 153 of the Constitution of Malaysia grants the Yang di-Pertuan Agong (The King) responsibility for safeguarding the special position of the malays and the bumiputras. The bumiputras are granted special rights in the form of reserved slots in local universities, colleges and other public education institutions. They also have special land reservations and places are set aside for the bumiputras especially the malays in the civil and military services. The constitution also provides for special privileges for the bumiputras in terms of scholarship and business permits. The article 153 led to the implementation of affirmative action policies which benefit only the bumiputras. This has created a racialist distinction between malaysians of different ethnic background. It is rather difficult to balance meritocracy with affirmative action.

After the May 1969 riots National Operations Council (NOC) was set up to rule the country until 1971. The NOC proposed that the Sedition Act be amended to make questioning of Article 153 illegal. Parliament passed the amendments as law when it reconvened in 1971. In line with the Article 153, first the National Economic Policy (NEP) and later the National Development Policy (NDP) was introduced to assist the malays and the bumiputras.

In 2003, the then prime minister Mahathir began to remind the malays to abandon their "crutches," and he implemented a policy of "meritocracy". Some branded this “meritocracy” as a sham because it divided students into two streams prior to university admission. The bumiputras went colleges or universities where they did a matriculation course and the non-malays had to do the Sijil Tinggi Pelajaran Malaysia (STPM) examination which was considered to be much more difficult and competitive examination as compared to the matriculation examination.

The idea of implementing total meritocracy in Malaysia does and will continue to face strong resistance and objections from some sections of the Malaysian society. The main opposition to the full implementation of meritocracy is from politicians who want to maintain unity among the malays so that UMNO can maintain their dominant position to have control over the government and administration of the country [21].

Conclusion

The word meritocracy was first coined by Michael Young in 1958. It is supposed to be a system where talented people move upward in society based on their achievement. Though many around the world believe that rewards in life such as university admissions, jobs, money and power should be based on skill and effort rather than lottery of birth or hereditary aristocracy. The reality is that the impact of merit on upward social mobility remains limited.

More people advance in life due to random factors, such as relatives, friends, chance meetings etc, rather than from the knowledge, IQ and the qualification that they posses. Therefore many believe that meritocracy as defined by most people is a myth.

There is discrimination in most societies where privileged groups, privileged races and social elites progress upwards much more easily and faster than other groups or individual.

Some have described meritocracy as a paradox because in meritocratic organization there is more discrimination then in non-meritocratic organizations.

In Malaysia all are ‘not equal’ and this inequality is guaranteed by our constitution. Our government’s affirmative policies to raise the economic standard of the bumiputras are contradictory the concept of meritocracy. The main opposition to the implementation of meritocracy in Malaysia comes from politicians who want to remain in power and control the government and administration of the country. Meritocracy is unlikely to be implemented in malaysia in the near or distant future.

References

Michael Young. The Rise of the Meritocracy, 1870-2033: An Essay on Education and Equality. London: Thames and Hudson, 1958.
Merriam-Webster dictionary at https://www.merriam-webster.com/dictionary/meritocracy. Accessed on 9/3/19.
Mark C. A belief in meritocracy is not only false: it’s bad for you. At https://aeon.co/ideas/a-belief-in-meritocracy-is-not-only-false-its-bad-for-you , accessed on 13/3/19.
National Centre for Social Research. (2011). British Social Attitudes Survey, 2009. [data collection]. UK Data Service. SN: 6695, http://doi.org/10.5255/UKDA-SN-6695-1.
McManus IC.Social class data are problematic to interpret, BMJ e-letter, 27 Jun 2004 at http://bmj.com/cgi/eletters/328/7455/1545#64772.
Saunders. Social mobility in Britain: An empirical evaluation of two competing theories.Sociology 1997;31, no. 2: 261–88.
Themelis S. Meritocracy through education and social mobility in post-war Britain: A critical examination. British Journal of Sociology of Education. 2008; 29:5, 427-438.
Morrell P. Britain is not a meritocracy…response to ‘The standardised admission ratio for measuring widening participation in medical schools: analysis of UK medical school admissions by ethnicity, socioeconomic status, and sex’ at https://www.bmj.com/rapid-response/2011/10/30/britain-not-meritocracy%E2%80%A6 accessed on 20/3/19.
Reay D. Review of Jo Littler, Against Meritocracy: Culture, Power, and Myths of Mobility at https://www.theoryculturesociety.org/review-jo-littler-meritocracy-culture-power-myths-mobility/ accessed on 21/3/19.
Castilla EJ., and Benard S. “The Paradox of Meritocracy in Organizations.” Administrative Science Quarterly 55 (2010): 543-576. © 2010 by Johnson Graduate School, Cornell University.
Kluegel, J. R., and E. R. Smith 1986 Beliefs about Inequality: American’s Views of What Is and What Ought to Be. New York: de Gruyter.
Ladd, E. C. 1994 The American Ideology. Storrs, T: Roper Center for Public Opinion Research.
Ladd, E. C., and K. H. Bowman. 1998 Attitudes toward Economic Inequality. Washington, DC: EI Press.
Scully MA. 1997 “Meritocracy.” In P. H. Werhane and R. E. Freeman (eds.), Blackwell Encyclopedic Dictionary of Business Ethics: 413–414. Oxford: Blackwell.
Scully MA. 2000 “Manage your own employability: Meritocracy and the legitimation of inequality in internal labor markets.” In C. R. Leana and D. Rousseau (eds.), Relational Wealth: The Advantages of Stability in a Changing Economy: 199–214. New York: Oxford University Press.
McNamee SJ and Miller RK. 2004 The Meritocracy Myth. Lanham, MD: Rowman and Littlefield.
Castilla EJ. 2008 “Gender, race, and meritocracy in organizational careers.” American Journal of Sociology,113: 1479–1526.
Monin, B., and D. T. Miller 2001 “Moral credentials and the expression of prejudice.” Journal of Personality and Social Psychology, 81: 5–16.
Uhlmann, E. L., and G. L. Cohen. 2007 “I think it, therefore it’s true”: Effects of self perceived objectivity on hiring discrimination.” Organizational Behavior and Human Decision Processes, 104: 207–223.
Crandall, C. S., and A. Eshleman. 2003 “A justification-suppression model of the expression and experience of prejudice”. Psychological Bulletin, 129: 414–446.
Hamzah Bin Ali. The Politics of Meritocracy in Malaysia at https://apps.dtic.mil/dtic/tr/fulltext/u2/a420243.pdf accessed on 2/4/19.

Monday, 4 March 2019

Acquired Spondylosis following spinal fusion

Dr KS Dhillon

Intervertebral Disc and spondylosis

The intervertebral discs are fibrocartilaginous, cylindrical structures which connect adjacent vertebral bodies. The disc consists of a central nucleus pulposus which is surrounded by the annulus fibrosus. The intervertebral discs undergo changes with age leading to degenerative disc disease (DDD) of the spine. The discs loses hydration and elasticity with age.

For the diagnosis of DDD, magnetic resonance imaging (MRI) is the most commonly used imaging modality. The degenerative changes in the disc on MRI imaging can be graded using the Pfirrmann grading system [1]. MRI T2 spin-echo weighted images are used for grading. There are 5 grades of changes in disc degeneration:

Grade I, where the disc is homogeneous with bright hyperintense white signal intensity and normal disk height.
Grade II, where the disc is inhomogeneous, but the hyperintense white signal nucleus and annulus are clearly differentiated. A gray horizontal band could be present. The disc height is preserved.
Grade III, where the disc is inhomogeneous with intermittent gray signal intensity. The distinction between nucleus and annulus is not clear. The disc height is normal or slightly decreased.
Grade IV, where the disc is inhomogeneous with a hypointense dark gray signal intensity. There is no distinction between the nucleus and annulus. The disc height is slightly or moderately decreased.
Grade V, where the disc is inhomogeneous with a hypointense black signal intensity. There is no distinction between the nucleus and the annulus. The disc space is markedly narrow.

As the disc space narrows the facets override and this increases motion at that spinal segment and further hastens the damage to the disc. Annular fissures and herniation can occur and facet joints undergo hypertrophy.

Marginal osteophytes begin to develop. These osteophytes stabilize the vertebral bodies adjacent to the level of the degenerating disc and increase the weight-bearing surface of the vertebral endplates. Degeneration of the joint surfaces and hypertrophy of ligaments decreases motion and this acts as a limiting mechanism against further deterioration. Degeneration of the disc and facet joints, hypertrophy of ligaments and formation of osteophytes defines the spectra of spinal spondylosis.

Acquired spondylolysis after spinal fusion

Spinal fusion, also know as spondylodesis or spondylosyndesis, is a surgical procedure where two or more vertebral segments are joined together or fused so that no movement occurs between the fused segments.

Spinal fusion is usually carried out for spinal instability. The spine can be divided into three columns namely anterior, middle, and posterior columns [2]. Generally, two of three columns must be anatomically intact for functional stability. Instrumentation is usually necessary if more than one column of the spine is disrupted.The instability may be from birth as in spondylolisthesis or acquired due to trauma or from tuberculosis, metabolic, degenerative or neoplastic disorders of the spine and sometimes from iatrogenic causes.

Most spinal segmental fusions are carried out using instrumentation such as plates for anterior spinal fusions and pedicular screws with rods for posterior fusions. The instrumentation immobilizes the segments allowing for bony growth and a successful fusion.

The long-term sequelae of spinal fusion, despite its frequent success, is that there is a loss of mobility at the fused segments and this places increased stresses on adjacent segments of the vertebral column. There is an increase in motion in the adjacent segment after spinal fusion or spinal instrumentation as compared to the normal state and the increase is more in two level fusion as compared to a one level fusion [3]. These increased stresses can increase the likelihood of degenerative changes, ligamentous instability, and even stress fracture at the mobile adjacent segments.

The adjacent segment pathology or abnormality has been classified into two categories by Hilibrand and Robbins [4], the first being "adjacent segment degeneration" and other "adjacent segment disease". Radiographic changes in the adjacent segment to the fusion without symptoms is called "adjacent segment degeneration" and radiographic changes with clinical symptoms is known as "adjacent segment disease".

Some are of the opinion that the term "adjacent segment degeneration or disease" is ambiguous and Riew et al. [5] proposed the term "adjacent segment pathology" (ASP), which includes any change that occurs adjacent to a previously operated level. They further subdivided ASP into asymptomatic "radiographic ASP" (RASP) and symptomatic "clinical ASP" (CASP). Adjacent segment changes may be seen at one or even two level.

Park et al [6] did a literature review to study the definition, etiology, incidence, and risk factors associated with adjacent segment disease. They found that the most common abnormal finding at the adjacent segment was disc degeneration. Increased intradiscal pressure, increased facet loading, and increased mobility at the adjacent segment after fusion leads to biochemical changes which cause adjacent segment disease. Age is also a major contributor to progressive spinal degeneration. At a follow up ranging from 36 to 369 months after fusion the incidence of radiographic changes at the adjacent disc varies from 5.2% to 100%. The incidence of symptomatic adjacent segment disease, however, is much lower, ranging from 5.2 to 18.5% at 44.8 to 164 months follow-up. They also found that the incidence of symptomatic disease was higher in patients with transpedicular instrumentation (range between 12.2-18.5%) as compared to other forms of instrumentation or with no instrumentation (range between 5.2-5.6%). They found that the potential risk factors were the type of instrumentation used, the fusion length, sagittal malalignment, facet injury during surgery, age, and pre-existing degenerative changes.

Radiographic asymptomatic adjacent segment disease though common, it however, does not correlate with functional outcomes.

Harrop et al [7] in a review of 27 studies found that the incidence of RASP ranged from 8% to 100% and the incidence of CASP ranged from 0% to 27.5%. This result suggests that radiographic degenerative changes at adjacent segments are common; however, clinical symptoms are less likely to be manifested. The incidence of revision surgery for ASP is low at between 0.74% to 15% [7,8].
Booth et al. [9] on the other hand reported that although radiological degenerative change were common 5 years after lumbar vertebral fusion; there were no cases with symptom. Several other authors also noted that there was no correlation between radiological change and clinical symptoms [ 10,11,12,13].

Soh et al [14] found that on more than 5 years follow up of patients with pedicle screw fixation and fusion, the patients’ gender, age, residential area, fusion method, the number of fusion segments, and the degree of preoperative adjacent disc degeneration on MRI showed no significant relationship with the postoperative degenerative change at the adjacent segments. They, however, found that there was a significantly positive correlation between the fusion segment lordotic angle per level and the postoperative degenerative change. Restoration of the fusion segment lordotic angle per level to >15° reduced the incidence of degenerative change at the adjacent segments.

Conclusion

The long-term sequelae of spinal fusion is that there is a loss of mobility at the fused segments and this places increased stresses on adjacent segments of the vertebral column. This increased stresses lead to degenerative changes in the adjacent mobile segments. These changes are usually known as adjacent segment pathology (ASP). If the patient is asymptomatic it is referred to as radiographic ASP (RASP) and if symptomatic it is known as clinical ASP (CASP).

The incidence of RASP ranges from 8% to 100% and the incidence of CASP ranges from 0% to 27.5%. Some authors report that there is no correlation between radiographic changes and clinical symptoms. The incidence of revision surgery for ASP is low at between 0.74% to 15%.
There are conflicting reports regarding the risk factors for ASP. Adjacent segment degeneration can also occur due to aging irrespective of the presence or absence of spinal fusion.

References

Pfirrmann CW, Metzdorf A, Zanetti M et-al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine. 2001;26 (17): 1873-8.
Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983;8:817– 831.
Brooker et al. Segmental biomechanics after single and multi-level lumbar spine fusion. 27th Annual Scientific Meeting of the Spine Society of Australia, 8-10 April 2016, Melbourne, Vic.
Hilibrand AS, Robbins M. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Spine J. 2004;4(6 Suppl):190S–194S.
Riew KD, Norvell DC, Chapman JR, Skelly AC, Dettori JR. Introduction/Summary statement: adjacent segment pathology. Spine (Phila Pa 1976) 2012;37(22 Suppl):S1–S7.
Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976). 2004 Sep 1;29(17):1938-44.
Lee JC, Kim Y, Soh JW, Shin BJ. Risk factors of adjacent segment disease requiring surgery after lumbar spinal fusion: comparison of posterior lumbar interbody fusion and posterolateral fusion. Spine (Phila Pa 1976) 2014;39:E339–E345.
Liang J, Dong Y, Zhao H. Risk factors for predicting symptomatic adjacent segment degeneration requiring surgery in patients after posterior lumbar fusion. J Orthop Surg Res. 2014;9:97. Published 2014 Oct 12. doi:10.1186/s13018-014-0097-0
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Friday, 22 February 2019

Calcaneal fractures

Dr KS Dhillon

Anatomy

The calcaneus also known as os calcis is the largest of the tarsal bones. It is situated at the back of the foot and it transmits the body weight from the body to the ground. It gives attachment to the muscles of the calf at its posterior aspect. It is cuboidal in shape and has its long axis directed forward and lateralward. It has six surfaces, three of which are articular.

On the anterior part of the superior surface there is an oval shaped articular facet called the posterior articular surface which articulates with the posterior calcaneal facet on the undersurface of the talus. Anterior to the posterior articular surface is the middle articular surface which articulates with the middle calcaneal facet on the under surface of the talus. On the anterior part of the calcaneus there is the anterior articular surface which articulates with the anterior calcaneal facet on the talus.

The posterior part of superior surface is nonarticular and is convex from side to side, concave from before backward, and on it sits a mass of fat which lies in front of the tendoachilles.

The inferior surface of the calcaneus is non articular and it is wider behind and convex from side to side. Posteriorly it is bounded by a transverse elevation called the calcaneal tuberosity. It has a lateral process which gives origin to part of the Abductor digiti quinti and a the medial process which gives attachment to the Abductor hallucis, the Flexor digitorum brevis and the plantar aponeurosis.

The lateral surface is nonarticular, flat, broad behind and narrow in front, and almost subcutaneous. At the centre is a tubercle which gives attachment of the calcaneofibular ligament. Anteriorly on the upper part the lateral talocalcaneal ligament is attached. In front of the tubercle are two groves. The superior groove transmits the tendon of the Peroneal brevis tendon and the inferior groove transmits the Peroneal longus tendon.

The medial surface of the calcaneus is concave and is directed obliquely downward and forward along which run the plantar vessels and nerves from the leg to the sole of the foot. At the upper and distal part there is a horizontal eminence called the sustentaculum tali which gives attachment to a slip of the tibialis posterior tendon. The eminence is concave above and articulates with the talus. Below it is grooved through which passes the tendon of flexor hallucis longus. The medial surface gives origin to part of the Quadratus plantæ.It also gives attachment to the plantar calcaneonavicular ligament and to part of the deltoid ligament.

Anteriorly it somewhat triangular in form and articulates with cuboid. The medial border gives attachment to the plantar calcaneonavicular ligament.

The posterior surface is convex and is wider below than above. It can be divided into three areas. The middle part gives attachment to the tendo achilles and the plantaris. The lowest portion is covered by fibrous fatty tissue of the heel while the upper portion is covered by a bursa which intervenes between it and the tendo achilles.

Epidemiology

Calcaneus is the most common tarsal bone to fracture. Calcaneal fractures account for about 1% to 2% of all fractures [1]. About 17% of the fractures are open fractures.

Mechanism of Injury, Fracture Type, and Classification

The fractures result from, traumatic axial loading following a fall from a height and from motor-vehicle accidents. Calcaneal fractures are broadly divided into two categories namely the extraarticular and intraarticular fractures. About 75% of the fractures are intraarticular.

Intraarticular Fractures

Intraarticular fractures result from axial loading, which produces shear and compression fracture lines [2]. The shear fracture occurs in the sagittal plane and traverses the posterior facet splitting the calcaneus into an anteromedial or sustentacular fragment and a posterolateral or tuberosity fragment [3]. The articulation of the posterior facet with the talus is usually maintained medially because of the medial talocalcaneal and interosseous ligaments. The lateral fragment is angulated (dislocated) laterally and remains impacted leading to a step in the posterior facet. The talus sometimes continues to impact on the lateral edge of the medial fragment and this creates a “double split” in the calcaneus resulting in a middle fragment.

The compression fracture line is usually produced when the anterolateral process of the talus wedges into the angle of Gissane. The fracture runs through the coronal plane and it can extend medially to split the middle facet as well as the anteromedial fragment. Viewed from the side a compression fracture looks like a an inverted “Y,” where the posterior limb runs horizontally towards the tuberosity as a “tongue type” fracture or it runs more vertically, just posterior to the posterior facet, as a “joint depression type” fracture [4]

Classification and treatment of Intraarticular fractures

There are several classifications for intraarticular fractures but the most commonly used is the one by Sanders. For this classification sagittal reconstructed CT images which are parallel and perpendicular to the posterior facet of the subtalar joint are necessary [5,6,7].

The type I fractures are nondisplaced. In type II fractures there are two articular pieces involving the posterior facet. The type II fractures are further divided into types A, B, and C, depending on the location of the fracture line from the lateral to medial side. In type III fractures there are three articular pieces with a depressed middle fragment and are divided into types AB, AC, and BC, depending on the location of the of the fracture lines. In type IV fractures there may be four or more articular fragments with high degree of comminution. The Sanders classification has been found to be useful in clinical practice [8]. It is not only useful in treatment planning but also useful in determining prognosis [5].

Undisplaced fractures are treated conservatively. Type II fractures treated surgically can yield excellent to good results in about 73% of the patients and in type III fractures the results can be good to excellent in about 70% of the patients [5].

Vasukutty et al [9] did a retrospective review of 80 intra-articular calcaneal fractures treated with open reduction and internal fixation. Internal fixation was carried out through the lateral approach and the fractures were fixed with plates. Clinical and radiological evaluation was carried out. There were 3 open fractures. The mean follow-up was 72 months (range 12 - 130 months). The mean age of the patients was 49 years (range 17 to 73 years). The mean Bohler’s angle improved to 26 degrees post-operatively from 6° preoperatively. The mean foot and ankle disability index score was 78.62, the mean SF-36® scores were 45.5 for the physical component and 52.6 for the mental component. The mean time to return to work in this study was 5.5 months.

Twelve patients (15%) developed symptomatic subtalar joint osteoarthritis. Four (5%) of these patients underwent subtalar fusion.

Classification and treatment of extraarticular Fractures

About 25% to 30% of calcaneal fractures are extraarticular. All calcaneal fractures that do not involve the posterior facet are included in this category.

Extraarticular calcaneal fractures are divided into 3 categories [10]:

(a) Avulsion fracture of anterior process by bifurcate ligament

(b) Fractures of the mid calcaneus including the body, sustentaculum tali,
peroneal tubercle, and lateral calcaneal process

(c) Avulsion fractures of the posterior calcaneus including the tuberosity and medial calcaneal tubercle

The extraarticular fractures can be treated conservative if they are undisplaced or minimally displaced. Depending on the type and location of the fracture, plating, wiring or screw fixation can be the treatment options.

Imaging for calcaneal fractures

Radiographs

Three views of plain radiographs namely the AP, lateral and oblique views are usually recommended for diagnosis of calcaneal fractures.

There are 3 optional views of plain radiographs which can be carried out depending on the circumstances. These include:

Broden view which allows visualization of posterior facet. It is useful for evaluation of intraoperative reduction of posterior facet. The x ray is done with the ankle in neutral dorsiflexion and about 45 degrees internal rotation. The films are obtained at 10, 20, 30, and 40 deg. of cephalic tilt.
Harris view demonstrates the body of the calcaneus, middle facet of the subtalar Joint and the sustentaculum tali. It helps visualize tuberosity fragment widening, shortening, and varus positioning. The foot is placed in maximal dorsiflexion and the x-ray beam is angled at 45 degrees.
AP (dorsoplantar) ankle view demonstrates lateral wall extrusion causing fibular impingement, delineates calcaneocuboid joint and demonstrates subluxation of talonavicular joint.

The lateral view is useful for measurement of the bohler’s angle and the angle of Gissane. The Bohler’s angle is formed by a line drawn from the highest point of the anterior facet to the highest point of the posterior facet and a line tangential to the superior edge of the tuberosity.

The angle is normally between 20 to 40 degrees. A decrease in Bohler’s angle represents a collapse of the posterior facet. The Bohler's angle has significant prognostic value in terms of predicting morbidity. A study by Loucks and Buckley [11] showed that fractures with markedly diminished Bohler's angle have a much poorer two-year outcome regardless of the type of treatment. Hence the initial Bohler's angle is highly prognostic, regardless of treatment modality.

The Gissane (crucial) angle is formed by the downward and upward slopes of the calcaneal superior surface. The normal value for this angle is between 120 to 145 degrees. An increase of this angle represents a collapse of posterior facet.

CT Scans

CT scans of the calcaneus are a must in the management of calcaneal fractures. A 30-degree semi coronal view demonstrates posterior and middle facet displacement. The axial view will demonstrate the involvement of the calcaneocuboid joint and a sagittal view will demonstrate any displacement of the tuberosity.

Complications

Some of the complications associated with calcaneal fractures include:

Wound complications occur in 10% to 25% of the patients. The incidence is higher in smokers, diabetics, and in patients with open injuries
Subtalar arthritis. The incidence of posttraumatic OA is about 15% [9]. The incidence is higher with nonoperative management of calcaneal fractures. The incidence of subtalar arthrodesis for symptomatic subtalar OA is 3.3% in patients who had operative treatment of the fracture and about 16.9% in patient who were treated nonoperatively [12].
Lateral impingement with irritation of peroneal tendon.
Flexor hallucis longus can be damaged by placement of lateral to medial screws especially at level of sustentaculum tali.
Compartment syndrome. The incidence of compartment syndrome after calcaneal fractures is between 1% to 10% [13].
Malunion. The Zwipp and Rammelt classification of calcaneal malunion is useful for management of malunions. It includes five types. Type I is characterised by subtalar incongruence with arthritis and a normal shaped calcaneus. In type II malunions there is additional heel varus or valgus. In type III malunions there is additional loss of hindfoot height and in type IV there is in addition translation of calcaneal tuberosity without varus or valgus. In type V malunions there is in addition talar tilt. Symptomatic type I malunions are treated with an in situ subtalar fusion. Type II and type III by bone block fusion and an osteotomy of the calcaneus. Type IV malunions are treated by oblique calcaneal osteotomy and subtalar fusion. Type V malunions are treated by bone block fusion and osteotomy.

Outcome of treatment of calcaneal fractures

Large series of good to excellent results after surgery of intraarticular calcaneal fractures have been published [5,14,15]. Most of the authors, however, compared their results to historical data and used different outcome measures. Furthermore, complications after surgery were not infrequent, and some of the complications were serious.

A few prospective randomized trials which compared surgical with nonsurgical treatment have been published in the past [16,17]. Randle et al [18] did a meta analysis to compare surgical versus nonsurgical treatment for calcaneal fractures. They found six articles which were suitable for the review. There was a tendency towards better outcome with surgical treatment but they could not find sufficient evidence to argue that operative treatment should be recommended for displaced intra articular fractures of the calcaneum.

Buckley et al [12] published a prospective randomized trial in 2002 with over 300 patients which showed that there were no differences in outcome between patients treated operatively and those treated nonoperatively. They were however able to identify subgroups of patients who might benefit from surgery.

Westphal et al [19] compared the general health of 71 patients who had surgical treatment of calcaneal fractures, 2.5 years after injury, with the general health of 71 people from the general population, using the SF-36 form. They compared the results of the examination with results of AOFAS Ankle Hindfoot Scale and Maryland Foot Score in the treated patients. They found significant limitations regarding general health in all 9 elements of the SF-36 form, in patients with calcaneal fractures. They concluded that patients with calcaneal fractures have significant limitations regarding general health.

In 2013 Veltman et al [20] carried out a systematic review of the literature to evaluate the long-term outcomes of 1,730 calcaneal fractures. They studied the functional and subjective outcome as well as did a radiographic evaluation at minimum of 2 years after either surgical or conservative treatment of calcaneal fractures. Their findings from the review supported the current clinical practice of treating displaced calcaneal fractures with open reduction and internal fixation.

Conclusion

Calcaneus is the largest of the tarsal bones and is the most frequent of the tarsal bones to fracture. The most common cause for the fracture is high-energy trauma which causes axial loading. About 75% of the fractures are intra-articular. Conventional x rays should include anteroposterior, axial, lateral and oblique views. CT scans are essential for classification and management of these fractures. There appears to be no consensus on conservative or surgical treatment of calcaneal fractures. Neither is there a consensus about the operative technique in treatment of calcaneal fractures. The treatment will depend on factors such as type of trauma, the type of fracture and condition of the skin.
The treatment options include no treatment, conservative treatment, open reduction, internal fixation, primary subtalar arthrodesis and a delayed primary arthrodesis.

Complications are common and include infections in about 10% to 25% of the patients, subtalar arthritis in about 15% of the patients and compartment syndrome in about 1% to 10% of the patients. Other complications include lateral impingement and injury to the flexor hallucis longus. Malunions are common and their treatment include calcaneal osteotomies and subtalar arthrodesis. The incidence of subtalar arthrodesis for symptomatic subtalar OA is 3.3% in patients who had operative treatment of the fracture and about 16.9% in patient who were treated nonoperatively.

The outcome of treatment of calcaneal fractures has not been good but most of recent studies show that open reduction and internal fixation has better outcome in selected patients.

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