Yellow flags are psychosocial associated with a greater likelihood of progression to persistent pain and disability. These are referred to as obstacles to recovery. Despite their recognized importance, it is unknown how effective clinicians are in detecting them. The primary objective of this study was thus to determine the effectiveness of spine specialist clinicians in detecting the presence of yellow flags in patients presenting to an orthopedic outpatient clinic with low back-related disorders. Overview of Literature: Psychosocial factors have been previously studied as important predictors of prognosis in patients with low back pain. However, the ability of spinal specialist to identify them remains unknown. Methods: A prospective, single-center, consecutive cohort study was conducted over a period of 30 months. All new patients with low back-related disorders regardless of pathology completed a Yellow Flag Questionnaire that was adapted from the psychosocial flags framework. Clinicians assessing these patients completed a standardized form to determine which and how many yellow flags they had identified during the consultation. Results: A total of 130 patients were included in the analysis, and the clinicians reported an average of 5 flags (range, 0-9). Fear of movement or injury was the most frequently reported yellow flag, reported by 87.7% (n=114) of patients. Clinician sensitivity in detecting yellow flags was poor, correctly identifying only 2 flags, on average, of the 5 reported by patients, with an overall sensitivity of only 39%. Conclusions: The ability of spine specialists to identify yellow flags is poor and can be improved by asking patients to complete a simple screening questionnaire.

IntroductionRadiological lumbar spinal instability may exist without obvious spondylolisthesis. We aim to determine the incidence of this non-spondylolisthetic cause of instability in conservatively managed patients and operated groups of patients. We also attempted to study the relationship between instability and its occurrence with respect to age, sex, signs and symptoms.Materials and methodsTwenty-three patients treated conservatively (group A) for non-spondylolisthetic backache were studied for radiological evidence of instability by evaluating angular rotation and sagittal translation at each lumbar motion segment. The influence of age, sex, signs and symptoms on the occurrence of instability was studied. A total of 18 patients treated surgically (group B) for non-spondylolisthetic backache in the form of discectomy/decompression were evaluated for occurrence of instability at three months, six months and nine months postoperatively.ResultsFour out of 23 patients (17.4%) in group A had radiological instability. Angular rotation was found to have negative correlation with age, while sagittal translation did not show any consistent correlation with age. Neither had any significant correlation with sex. The incidence of instability in patients treated with discectomy at three months and six months was 20% which reduced to 10% at nine months while that in patients treated with decompression was about 37.5% over three months, six months and nine months of follow-up.ConclusionIf patients with spondylolisthesis were excluded from the study, instability could still result from the rotational component in sagittal plane. Secondary iatrogenic instabilities do result in patients undergoing extensive decompression for spinal stenosis and should always be thought of.

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The case report discusses rare occurrence of multiple level fractures of cervical spine following trivial injury to the neck in a patient with osteopetrosis and its treatment with conservative management.

Background: Gartland type 3 supracondylar fractures of the humerus in children have been associated with serious complications and believed to benefit from an emergency treatment. However, several unavoidable factors sometimes lead to surgical delays even in tertiary hospital. The present study was undertaken to assess the functional and radiological outcome with respect to the timing of intervention post injury. Methods: In the observational study, paediatric patients with type 3 supracondylar humerus fractures were divided in 2 groups based on the timing of treatment, within 12 hours or after 12 hours of injury. The data was collected in a retrospective and prospective manner with minimum 9 months of follow-up and the study variables such as age, type of displacement, requirement of open reduction, period of immobilization, time for fracture union, change in range of motion and carrying angle and incidence of complication was noted. Results: The baseline variables was comparable in both the groups. There was no significant need of an open reduction in patients in both the groups. Following limb immobilization for 3-4 weeks after closed reduction, all patients had successful fracture union. There was no significant difference in change in the carrying angle and range of movement in both the groups. The incidence of complications was comparable in both the groups. Conclusion: We recommend that the surgery can be safely postponed to next available operation theatre in non-complicated cases of severe supracondylar fracture humerus to facilitate finest pre-operative care and an optimal care surgery.

Objective/Purpose:The objective of this study is to describe our experience with the use of stay sutures and transverse neck incision for anterior cervical spine surgeries involving multiple levels.Summary of Background Data:Transverse incisions on neck usually heal with minimal fibrosis resulting in cosmetically acceptable scars whereas vertical incision, although provides greater exposure, heals with extensive fibrosis resulting in ugly scars. Transverse incision is thus highly recommended. However, the fear of nonextensibility of transverse incision for multilevel fusion has led to the preference of vertical incision, development of techniques for identifying the optimal level of the incision, or has suggested the usage of two transverse incisions.Materials and Methods:Seventy-six patients underwent anterior cervical spine surgeries using a transverse neck incision for single or multilevel discectomy/corpectomy and fusion. Having divided the platysma, dissection was carried down to the anterior surface of the cervical spine between the carotid sheath laterally and the trachea and esophagus medially. Stay sutures were taken through the platysma and subcutaneous tissue, converting the transverse incision into a quadrilateral window providing access for as much as three-level corpectomy or five levels of fixation.Results:All the wounds healed with no evidence of wound-related complications, leaving a cosmetically acceptable scar.Conclusion:Using appropriately placed stay sutures, a transverse neck incision taken in the middle of the field of work can provide enough of a surgical window to perform multilevel fusion surgeries. Its simplicity and cost-effectiveness make it easily implementable, addressing the underlying pathology adequately with best possible cosmetic results.

Fractures of the proximal tibia comprise a huge spectrum of injuries with different fracture configurations. The combination of tibia plateau fracture with diaphyseal extension is a rare injury with sparse literature being available on treatment of the same. Various treatment modalities can be adopted with the aim of achieving a well-aligned, congruous, stable joint, which allows early motion and function.We report a case of a 40-year-old male who sustained a Schatzker type VI fracture of left tibial plateau with diaphyseal extension. On further investigations, the patient was diagnosed to have diabetes mellitus with grossly deranged blood sugar levels. The depressed tibial condyle was manipulated to lift its articular surface using K-wire as a joystick and stabilized with an additional K-wire. Distal tibial skeletal traction was maintained for three weeks followed by an above knee cast. At eight months of follow-up, X-rays revealed a well-consolidated fracture site, and the patient had attained a reasonably good range of motion with only terminal restriction of squatting.Tibial plateau fractures with diaphyseal extension in a patient with uncontrolled diabetes mellitus is certainly a challenging entity. After an extended search of literature, we could not find any reports highlighting a similar method of treatment for complex tibial plateau injuries in a patient with uncontrolled diabetes mellitus.

How to cite this article: Palliyil N, Dhake R, Olakunle B, et al. Clinical dilemma in the management of an unstable spinal fracture in a frail older patient with multiple comorbidities-conservative versus non-conservative care. A case report.