Person: Yurac, Ratko
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Yurac
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Ratko
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Publication Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System(2022) Sheen Kweh, Barry Ting; Wee Tee, Jin; Muijs, Sander; Oner, Cumhur; Schnake, Klaus John; Benneker, Lorin Michael; Neves Vialle, Emiliano; Kanziora, Frank; Rajasekaran, Shanmuganathan; Schroeder, Gregory; Vaccaro, Alexander R.; AO Spine Subaxial Injury Classification System Validation Group; Grin, Andrey; Abdelgawaad, Ahmed Shawky; Zubairi, Akbar Jaleel; Castillo, Alejandro; Vernengo Lezica, Alejo; Ramieri, Alessandro; Guiroy, Alfredo; Grundshtein, Alon; Godinho Jr., Amauri; Henine, Amin; Pershin, Andrei A.; Athanasiou, Alkinoos; Zarate-Kalfopulos, Baron; Benzarti, Sofien; Bernucci, Claudio; Rebholz, Brandon J.; Direito-Santos, Bruno; Lourenço Costa, Bruno; Saciloto, Bruno; Majer, Catalin; Tannoury, Chadi; Cheng, Cristina; Yin Cheung, Jason Pui; Konrads, Christian; Jetjumnong, Chumpon; Chung, Chun Kee; Popescu, Eugen Cezar; Kilinçer, Cumhur; Yurac, RatkoOBJECTIVE Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty. METHODS A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants’ management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine. RESULTS In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001). CONCLUSIONS The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.Publication CT Scan in Subaxial Cervical Facet Injury: Is It Enough for Decision-Making?(2023) Cabrera, Juan P.; Yurac, Ratko; Joaquim, Andrei F.; Guiroy, Alfredo; Carazzo, Charles A.; Zamorano, Juan José; Valacco, Marcelo; AO Spine Latin America Trauma Study GroupStudy Design: Cross-sectional survey. Objectives: Assessment of subaxial cervical facet injuries using the AO Spine Subaxial Cervical Spine Injury Classification System is based on CT scan findings. However, additional radiological evaluations are not directly considered. The aim of this study is to determine situations in which spine surgeons request additional radiological exams after a facet fracture. Methods: A survey was sent to AO Spine members from Latin America. The evaluation considered demographic variables, routine use of the Classification, as well as the timepoint at which surgeons requested a cervical MRI, a vascular study, and/ or dynamic radiographs before treatment of facet fractures. Results: There was 229 participants, mean age 42.9 ± 10.2 years; 93.4% were men. Orthopedic surgeons 57.6% with 10.7 ± 8.7 years of experience in spine surgery. A total of 86% used the Classification in daily practice. An additional study (MRI/vascular study/and dynamic radiographs) was requested in 53.3%/9.6%/43.7% in F1 facet injuries; 76.0%/20.1%/50.2% in F2; 89.1%/65.1%/28.4% in F3; and 94.8%/66.4%/16.6% in F4. An additional study was frequently required: F1 72.5%, F2 86.9%, F3 94.7%, and F4 96.1%. Conclusions: Spine surgeons generally requested additional radiological evaluations in facet injuries, and MRI was the most common. Dynamic radiographs had a higher prevalence for F1/F2 fractures; vascular studies were more common for F3/F4 especially among surgeons with fewer years of experience. Private hospitals had a lower spine trauma cases/year and requested more MRI and more dynamic radiographs in F1/F2. Neurosurgeons had more vascular studies and dynamic radiographs than orthopedic surgeons in all facet fractures.Publication Treatment of unilateral cervical facet fractures without evidence of dislocation or subluxation: a narrative review and proposed treatment algorithm(2024) Cirillo, Juan; Ricciardi, Guillermo; Alvarez, Facundo; Guiroy, Alfredo; Yurac, Ratko; Schnake, KlausIsolated cervical spine facet fractures are often overlooked. The primary imaging modality for diagnosing these injuries is a computed tomography scan. Treatment of unilateral cervical facet fractures without evidence of dislocation or subluxation remains controversial. The available evidence regarding treatment options for these fractures is of low quality. Risk factors associated with the failure of nonoperative treatment are: comminution of the articular mass or facet joint, acute radiculopathy, high body mass index, listhesis exceeding 2 mm, fragmental diastasis, acute disc injury, and bilateral fractures or fractures that adversely affect 40% of the intact lateral mass height or have an absolute height of 1 cm.Publication Flexion teardrop fracture of the cervical spine: a narrative review(2025) Cirillo, Ignacio; Blanco, Sebastián; Cabello, Sebastián; Ricciardi, Guillermo; Guiroy, Alfredo; Yurac, Ratko; on behalf AO Spine Latin America Trauma Study GroupTeardrop fractures of the cervical spine are characterized by a triangular-shaped fragment located in the anteroinferior corner of the vertebral body. Flexion-type teardrop fractures are highly unstable injuries resulting from a flexion-compression mechanism. A notable feature of these injuries is retrolisthesis of the vertebral body, which is often associated with a high risk of neurological compromise. The anterior approach is the most commonly used surgical treatment for flexion-type teardrop fractures. In contrast, extension-type teardrop fractures primarily affect the axis vertebral body and are generally stable injuries that can be treated nonoperatively.Publication Time to Surgery for Subaxial Cervical Fractures: A Multicenter Study(2025) Quinteros, Guisela; Ricciardi, Guillermo; Cirillo, Ignacio; Marquez, Edgar; Cabrera, Juan; Carazzo, Charles; Yurac, Ratko; Guiroy, AlfredoObjective: To identify delays for surgery to stabilize subaxial cervical fractures and the main reasons for them across Latin America. Methods: This is a retrospective multicenter cohort study of patients surgically treated for subaxial cervical fractures from 13 spine centers across Latin America from January 1, 2014 to January 1, 2023. Causes of delay to surgery beyond 24 hours were documented. Results: We included 529 patients from 13 institutions in Latin American countries; 408 (77.1%) males and 121 (22.9%) females with a mean age of 43.4 (standard deviation = ±16.2). Predominantly caused by traffic accident (n = 256; 48.4%), followed by fall from height (n = 233; 44%). Mostly, suffered type C fractures (n = 348; 65.8%) and/or neurological injury (n = 384; 72.6%). The time from admission to surgery was >72 hours in 70% of the patients included (n = 375; 70.9%). More than 45% waited longer than a week (n = 257; 48.6%) for spine surgery. Only 12.5% (n = 66) of the patients received surgery in the first 24 hours from admission. The primary reasons for the surgical delay were the necessity for other surgical procedures (n = 161; 34.8%), the unavailability of surgical implants (n = 60; 13.0%), patient clinical instability (n = 55; 11.9%), and delays in referral (n = 38; 8.2%). Conclusions: We documented significant and concerning delays in providing spinal decompression and stabilization surgery to patients with cervical spine fractures. Only 17% of patients have surgery in the recommended time <24 hours, more than half of the patients must wait for more than 72 hours, and nearly half of patients wait for longer than a week.Publication Mechanical Instability After Civilian Thoracolumbar Gunshot Injuries: A Systematic Review to Support Classification Development(2025) Ricciardi, Guillermo; Cirillo, Ignacio; Cabrera, Juan; Alvarenga, Otávio; Neves, Emiliano; Carazzo, Charles; Dittmar, Michael; Guiroy, Alfredo; Yurac, Ratko; Schroeder, GregoryStudy DesignSystematic Review.ObjectivesIdentify risk factors for mechanical instability in thoracolumbar gunshot wounds to develop a new classification system.MethodsA systematic review following PRISMA 2020 guidelines was conducted across multiple databases from January 1, 1990, to September 12, 2024 (PROSPERO: CRD42023458804).ResultsOf 2400 records, 33 studies (3195 patients) met inclusion criteria, mostly retrospective and single-center, with varying definitions of instability. Direct comparison was limited due to clinical heterogeneity. Only 12 studies defined mechanical instability, mainly using the Denis three-column theory. Instability was reported in less than 10% of cases, except for one higher-rate outlier. The main markers included vertebral body comminution and potential ligamentous injury. Management was mainly conservative, with a low fixation rate (1.5-9.7%). Imaging relied on CT and static X-rays, with some studies advocating for dynamic radiographs.ConclusionThere is a lack of standardized definitions for mechanical instability in civilian thoracolumbar gunshot injuries. Four recurrent unstable patterns were detected, with vertebral body comminution as the most consistent marker. The need for a standardized classification system and further prospective studies is evident.