Roadblocks to early surgery for patients with cervical spine injury

Traumatic cervical spine injuries (TCSI) are rare injuries. With increasing age the incidence of TCSI is on the rise. TCSI and traumatic brain injury (TBI) are often associated. Both TCSI and TBI are allocated to the Abbreviated Injury Scale (AIS) head region. However, the nature and outcome of these injuries are potentially different. Therefore, the aim of this study was to investigate the epidemiology, demographics and outcome of severely injured patients with severe TCSI, and compare them with polytrauma patients with severe TBI in the strict sense. Consecutive polytrauma patients aged ≥ 15 years with AIShead ≥ 3 who were admitted to a level-1 trauma center Intensive Care Unit (ICU) from 2013 to 2021 were included. Demographics, treatment, and outcome parameters were analyzed for patients who had AIShead ≥ 3 based on TCSI and compared to patients with AIShead ≥ 3 based on proper TBI. Data on follow-up were collected for TCSI patients. Two hundred eighty-four polytrauma patients (68% male, Injury Severity Score (ISS) 33) with AIShead ≥ 3 were included; Thirty-one patients (11%) had AIShead ≥ 3 based on TCSI whereas 253 (89%) had AIShead ≥ 3 based on TBI. TCSI patients had lower systolic blood pressure in the Emergency Department (ED) and stayed longer in ICU than TBI patients. There was no difference in morbidity and mortality rates. TCSI patients died due to high cervical spine injuries or respiratory insufficiency, whereas TBI patients died primarily due to TBI. TCSI was mainly located at C2, and 58% had associated spinal cord injury. Median follow-up time was 22 months. Twenty-two percent had improvement of the spinal cord injury, and 10% died during follow-up. In this study the incidence of severe TCSI in polytrauma was much lower than TBI. Cause of death in TCSI was different compared to TBI demonstrating that AIShead based on TCSI is a different entity than based on TBI. In order to avoid data misinterpretation injuries to the cervical spine should be distinguished from TBI in morbidity and mortality analysis.

Introduction to the Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries

This study is nationwide retrospective multi-center study to investigate the incidence and characteristics of blunt cerebrovascular injury (BCVI) in elderly Japanese patients with traumatic cervical spine injuries (CSI) including spinal cord injury (SCI) without major bone injury. The study enrolled 1512 patients (average age: 75.8 ± 6.9 years; 1007 males, 505 females) from 33 nationwide institutions, and 391 (26%) of the participants had digital subtraction angiography and/or computed tomography angiography. Fifty-three patients were diagnosed as having BCVI by angiography. We assessed neurological evaluation, comorbidities and classification of CSI in the elderly patients with/without BCVI and collected 6-month follow-up data on treatment, complications, and patient outcome. We also statistically analyzed the relative risk (RR) and relationship between BCVI and other factors. Significant differences were identified between BCVI (+) (n = 53) and (–) (n = 1459) patients with American Spinal Injury Association Impairment Scale (ASIA) A, C, D, cervical fracture, C3-7 injury level (AO type F and/or C), cervical dislocation, spinal surgery for CSI, tetraplegia type of SCI, and/or head injury. Fifty-three (3.5%) elderly patients had CSI complicated by BCVI including 10 (19%) cases of Denver grade I, four (7%) of grade II, 1 (2%) of grade III, 29 (55%) of grade IV, and nine (17%) of grade V. Sixteen cases were treated by interventional radiology. Rates of mortality and brain infarction from BCVI were 0.13% and 0.40%, respectively. RR of BCVI was significantly higher in the elderly cervical injury patients with head injury, severe neurological deficit, ASIA A (RR: 4.33), cervical fracture at the C3-7 level (RR: 7.39), and cervical dislocation at the C1-6 level (RR: 3.06-7.18). In conclusion, 53 (3.5%) elderly patients were complicated with BCVI. BCVI more frequently complicated head injury, severe neurological deficit (ASIA A or tetraplegia), AO type F, and/or C fractures and cervical dislocation in these patients. Six patients (11%) suffered brain infarction and two patients died from BCVI.

Although traumatic cervical spine injuries in older adults are commonly caused by minor traumas, such as ground-level falls, their prognosis is often unfavorable. Studies examining the clinical characteristics of cervical spine injuries in older adults according to the external cause of injury are lacking. This study included 1512 patients of ≥ 65 years of age with traumatic cervical spine injuries registered in a Japanese nationwide multicenter database. The relationship between the external causes and clinical characteristics, as well as factors causing unfavorable outcomes at the ground-level falls, were retrospectively reviewed and examined. When fall-induced cervical spine injuries were categorized and compared based on fall height, the patients’ backgrounds and injury statuses differed significantly. Of note, patients injured from ground-level falls tended to have poorer pre-injury health conditions, such as medical comorbidities and frailty, compared with those who fell from higher heights. For ground-level falls, the mortality, walking independence, and home-discharge rates at 6 months post-injury were 9%, 67%, and 80%, respectively, with preexisting medical comorbidities and frailty associated with unfavorable outcomes, independent of age or severity of neurological impairment at the time of injury.

Background:We present a review of the results of the current surgical management of acute cervical spine injuries in the Federal Capital Territory, Abuja, Nigeria. This is the first detailed retrospective study on the surgical management of patients with cervical spine injuries from Nigeria.Methods:The medical reports of patients with traumatic cervical spine and spinal cord injuries undergoing surgery from 1 August 2009 till 30 August 2010 were reviewed. Management and early results of outcome were ascertained and detailed consecutively in a prospective Microsoft Office Access® database (Microsoft Group of Companies). Frankel grading was used for pre- and immediate post-operative evaluation (within 48 hours). The Barthel index (BI) was used to classify patients as dependent or independent at follow-up.Results:Twenty consecutive patients presented with acute cervical spine and spinal cord injuries since August 2009. Twenty anterior cervical spine decompression and fixation with an iliac graft and an anterior cervical plate (ACDF) were performed in 18 patients. All operations were performed with general anaesthesia using standard techniques but without a microscope or a high speed drill. Of the 18 patients who were operated, 4 patients died within a short period following surgical intervention. Seven patients have made a full recovery and seven remain fully dependent. Only two of the dependent quadriplegic patients have become reintegrated back into the society.Conclusion:The management of spinal cord injuries in Abuja is evolving. The operations were performed adequately with much limited complement of equipment. Poor intensive care therapy is a major challenge and improvements in this area of care will likely lead to better patient outcomes.

Traumatic cervical spinal injuries can severely affect respiratory function and cause significant morbidity and mortality. The typical respiratory morbidity in cervical spine injury is Atelectasis, Ventilator-associated pneumonia, acute respiratory distress syndrome and delayed weaning, etc. The study aims to see the prevalence of respiratory morbidity as well as mortality associated with cervical spine injury. Cross sectional study based on retrospective data was conducted on the X Sciences with the existing hospital record during the period of 3 years to find out the prevalence respiratory morbidity like Ventilatory Associated Pneumonia, delayed weaning, ARDS, atelectasis of traumatic cervical spine injury, determine the prevalence, type, and impact of respiratory morbidity and mortality in this population. Total no 76 patients data meeting the inclusion criteria included in study. Male patients were more prone to develop traumatic cervical spinal injuries (SCI). The prevalence of respiratory morbidity in term of VAP(57.89), delayed weaning(46.05) and Atelectasis(22.36) was high. Patients with Asia A Neurology has higher association for VAP and delayed weaning, while Asia E Neurology patients had no respiratory morbidity. The study found a significant positive association between respiratory morbidity with hospital stay, and ventilator days (p-value: 0.019 and 0.048). A total of 15 patients died, 28.95% were discharged on request and 40.8% leaving the hospital against medical advice. The prevalence of respiratory morbidity higher in cervical spine injury. Furthermore, it has associated with prolonged ICU and ventilator days and increase in mortality.

要旨【目的】鈍的頸椎損傷に合併する椎骨動脈損傷（以下VAI）は，時に重篤な脳梗塞を生じるが，確立された治療指針はない。我々は不安定型頸椎損傷に合併する椎骨動脈閉塞の症例を血管内治療の適応とし，整復固定術前に塞栓術を行ってきた。当院のVAI症例を検討し，椎骨動脈閉塞症例に対する塞栓術や長期予後について報告する。【対象】2015年1月～2018年4月に入院加療を行った全鈍的頸椎外傷症例を対象とした。頭頸部造影CT検査にてVAIの合併を認めた症例について，患者背景，頸椎損傷の形態，Denver grade，治療内容，脳梗塞合併の有無を後方視的に検討した。【結果】対象の鈍的頸椎外傷患者は89例で，15例（16.7%）にVAIを合併した。VAI患者の平均年齢は62.6歳で，半数が転倒転落を受傷機転とした。VAIの原因となった頸椎損傷は①亜脱臼，②環椎破裂骨折，③横突起骨折の3つであった。Denver grade IVの症例が最も多く12例であり，うち整復固定術を必要とした9例に血管内治療を行い，入院中および退院後のフォローにおいて明らかな脳梗塞を生じた症例は認めなかった。【結語】不安定性頸椎損傷に合併する椎骨動脈閉塞症例に対する整復固定術前の予防的塞栓術は，脳梗塞発症の予防に有効な治療手段となる可能性がある。

Motor vehicle collisions (MVCs) are the leading cause of spine and spinal cord injuries in the United States. Traumatic cervical spine injuries (CSIs) result in significant morbidity and mortality. This study was designed to evaluate both the epidemiologic and biomechanical risk factors associated with CSI in MVCs by using a population-based database and to describe occupant and crashes characteristics for a subset of severe crashes in which a CSI was sustained as represented by the Crash Injury Research Engineering Network (CIREN) database. Prospectively collected CIREN data from the eight centers were used to identify all case occupants between 1996 and November 2009. Case occupants older than 14 years and case vehicles of the four most common vehicle types were included. The National Automotive Sampling System's Crashworthiness Data System, a probability sample of all police-reported MVCs in the United States, was queried using the same inclusion criteria between 1997 and 2008. Cervical spinal cord and spinal column injuries were identified using Abbreviated Injury Scale (AIS) score codes. Data were abstracted on all case occupants, biomechanical crash characteristics, and injuries sustained. Univariate analysis was performed using a χ analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations. CSIs were identified in 11.5% of CIREN case occupants. Case occupants aged 65 years or older and those occupants involved in rollover crashes were more likely to sustain a CSI. In univariate analysis of the subset of severe crashes represented by CIREN, the use of airbag and seat belt together (reference) were more protective than seat belt alone (odds ratio [OR]=1.73, 95% confidence interval [CI]=1.32-2.27) or the use of neither restraint system (OR=1.45, 95% CI=1.02-2.07). The most frequent injury sources in CIREN crashes were roof and its components (24.8%) and noncontact sources (15.5%). In multivariate analysis, age, rollover impact, and airbag-only restraint systems were associated with an increased odds of CSI. Using the population-based National Automotive Sampling System's Crashworthiness Data System data, 0.35% of occupants sustained a CSI. In univariate analysis, older age was noted to be a significant risk factor for CSI. Airbag-only restraint systems and both rollover and lateral crashes were also identified as risk factors for CSI. In addition, increasing delta v was highly associated with CSIs. In multivariate analysis, similar risk factors were noted. Of all the restraint systems, seat belt use without airbag deployment was found to be the most protective restraint system (OR=0.29, 95% CI=0.16-0.50), whereas airbag-only restraint was associated with the highest risk of CSI (OR=3.54, 95% CI=2.29-5.46). Despite advances in automotive safety, CSIs sustained in MVC continue to occur too often. Older case occupants are at an increased risk of CSI. Rollover crashes and severe crashes led to a much higher risk of CSI than other types and severity of MVCs. Seat belt use is very effective in preventing CSI, whereas airbag deployment may increase the risk of occupants sustaining a CSI. More protection for older occupants is needed and protection in both rollover and lateral crashes should remain a focus of the automotive industry. The design of airbag restraint systems should be evaluated so that they are not causative of serious injury. In addition, engineers should continue to focus on improving automotive design to minimize the risk of spinal injury to occupants in high severity crashes.

The authors believe that the standardized and systematic study of immobilization techniques, diagnostic modalities, medical and surgical treatment strategies, and ultimately outcomes and outcome measurement after cervical spinal trauma and cervical spinal fracture injuries, if performed using well-designed medical evidence-based comparative investigations with meaningful follow-up, has both merit and the remarkable potential to identify optimal strategies for assessment, characterization, and clinical management. However, they recognize that there is inherent difficulty in attempting to apply evidence-based medicine (EBM) to identify ideal treatment strategies for individual cervical fracture injuries. First, there is almost no medical evidence reported in the literature for the management of specific isolated cervical fracture subtypes; specific treatment strategies for specific fracture injuries have not been routinely studied in a rigorous, comparative way. One of the vulnerabilities of an evidenced-based scientific review in spinal cord injury (SCI) is the lack of studies in comparative populations and scientific evidence on a given topic or fracture pattern providing level II evidence or higher. Second, many modest fracture injuries are not associated with vascular or neural injury or spinal instability. The application of the science of EBM to the care of patients with traumatic cervical spine injuries and SCIs is invaluable and necessary. The dedicated multispecialty author groups involved in the production and publication of the two iterations of evidence-based guidelines on the management of acute cervical spine and spinal cord injuries have provided strategic guidance in the care of patients with SCIs. This dedicated service to the specialty has been carried out to provide neurosurgical colleagues with a qualitative review of the evidence supporting various aspects of care of these patients. It is important to state and essential to understand that the science of EBM and its rigorous application is important to medicine and to the specialty of neurosurgery. It should be embraced and used to drive and shape investigations of the management and treatment strategies offered patients. It should not be abandoned because it is not convenient or it does not support popular practice bias or patterns. It is the authors' view that the science of EBM is essential and necessary and, furthermore, that it has great potential as clinician scientists treat and study the many variations and complexities of patients who sustain acute cervical spine fracture injuries.

Cervical spine injuries in the pediatric population are rare. Most injuries to the cervical spinal cord and vertebral column can be managed nonoperatively; however, surgical management may be required in certain clinical scenarios. A posterior surgical approach has been previously preferred; however, the utilization of anterior spinal fixation and instrumentation has been limited. We present a small case series of patients presenting with a traumatic cervical spine injury and detail the feasibility of craniocervical junction (CVJ) and subaxial spinal fixation in the pediatric population.We report four cases involving pediatric patients, all of whom presented with cervical spine injuries necessitating operative intervention using a combination of the anterior and posterior operative approaches. All four patients recovered well, did not require surgical revision, and were neurologically intact at the last follow-up. Therefore, we conclude that spinal arthrodesis is a safe, effective way to manage spinal injuries in the cervical spine following traumatic injury.

AimVertebral artery injury associated with blunt traumatic cervical spine injury sometimes causes severe cerebellar and brain stem infarction. No treatment guidelines for vertebral artery injury aimed at preventing stroke have been decided. We have conducted endovascular embolization in patients with up to Denver grade IV cerebrovascular injury complicated by unstable cervical spine injury before open reduction and fixation surgery. The purpose of this study was to validate the clinical course of vertebral artery injury and especially endovascular treatment for grade IV patients in our hospital.MethodsParticipants comprised of patients diagnosed as having traumatic cervical spine injury in our hospital between January 2015 and April 2018. Among these patients, we selected those with vertebral artery injury and retrospectively examined the background characteristics of the patients, details of treatment, and complications with or without stroke.ResultsTraumatic cervical spine injury was diagnosed in 89 patients. Among these patients, 15 (16.7%) showed a complicating vertebral artery injury. Mean age was 62.6 years, and almost 50% of the patients were injured in falls. Three types of cervical spine injury caused vertebral artery injury: subluxation, Jefferson fracture, and fracture involving the foramen transversarium. Vertebral artery injury was classified as grade IV in 12 patients, of whom nine required spinal surgery. All patients who needed spinal surgery underwent endovascular therapy before surgery, and none experienced a stroke.ConclusionEndovascular embolization of the vertebral artery occlusion in patients with unstable cervical spine injury before open reduction and fixation surgery can be a treatment option to prevent stroke.

Background: The epidemiology of traumatic cervical spine injury is not well documented in developing/ underdeveloped countries. There are a few single-centered studies on the epidemiology of cervical spine injury in Nepal. Objectives: This study aimed to explore the epidemiology of traumatic cervical spine injuries presented at Dhulikhel Hospital, Kathmandu University Hospital, Nepal. Methods: This was a retrospective study of individuals with traumatic cervical spine injuries admitted to the Department of Orthopedics from 2015 January to 2021 December. Data collection was done by using the International Spinal Cord Injury core data set (version 2) and International Spinal Cord Injury Spinal Column Injury Basic Data Set (version 1.0). Results: One hundred and forty-four patients were included of which the majority (68.8%) were males. The mean age of the patients was 47.89 ± 17 years. Fall injury was the most common etiology (79.2%). C2 was the most common level injured (28.5%). Patients with ASIA A neurology was 18% and surgical treatment was given to nearly 60%. The patients had a median hospital stay of 9 days (4- 16) and a mortality of 4.2%. Conclusion: There was a male predominance with a recent increase in the female proportion for traumatic cervical spine injury. Fall was the most common etiology with the majority of patients in their 30s and 40s. Surgical treatment is more preferred recently. The mortality rate was relatively low which needs further investigation.

BACKGROUND: Traumatic cervical spine injury is the commonest and most devastating injuries of the musculoskeletal system occurring more commonly in young patients from high energy vehicular accidents. This is particularly important considering the state of health care delivery system in Nigeria, increasing use of vehicles and belligerent flaunting of traffic rules. This study highlights the pattern of the injuries of the cervical spine as a distinct pathological entity which has not been documented before, the difficulties, the complications encountered and our attempt at overcoming these. METHODOLOGY: This is a three year prospective analysis of all patients with cervical spine injury. Treatment was conservative, Frankel's gradling was used as index of monitor, complications were documented and treated as they occurred and follow-up was for a minimum period of 12 months. RESULT: Twenty-eight patients were recruited comprising 25 (89.3%) males and three 910.7%) with a mean age of 30.5 (+5.54) years. Twenty five (89.3%) patients were aged 20.35 years. Road traffic accident was the leading cause in 22 (78.6%). Five (22.7%) patients of these had worsening of neurological status on transit to the hospital soon after the accidents. Ten (35.7%) patients had complete cord injury, 13(46.4%), incomplete and five had no cord injury at all. Twenty (71.4%) patients sustained associated injuries, facial lacerations and head injury being the commonest. Eleven (39.3%) patients had an improvement of at least one Frankel's grade during the course of rehabilitation. The commonest complications in our series were, urinary tract infection in 11 (39.3%); pressure ulcers in 11 (39.3%). Others were bronchopneumonia 9(32.1%); muscle spasms 9 (32.1%). Mortality was 7.1% both from respiratory failure. The mean duration of hospital stay was 95.4 (+78.5; range 0-2210 days. CONCLUSION: The outlook for the cervical injured patient remains bleak. More attention should be devoted to preventive measures backed by adequate and appropriate government legislation. The Federal Road Safety Corp should be empowered and their scope widened to increase their relevance in the community. A well run ambulance service scheme anchored by the ministry of health is long overdue and there is no better time than now to establish regional spinal center for adequate rehabilitation of the spinal injured patient. KEY WORDS: Traumatic cervical spine injury; Frankel's grade; urinary tract infection; bronchopneumonia, spinal center. Nigerian Journal of Orthopaedics and Trauma Vol.3(2) 2004: 149-163

Objectives To elucidate the incidence and risk factors for pneumonia after acute traumatic cervical spinal cord injury (CSCI) Design Retrospective cohort study. Setting: Spinal injuries center in Japan. Participants: Of 184 individuals who were admitted within 2 weeks after acute traumatic cervical spinal injuries, 167 individuals who met the criteria were included in this study. Interventions: The occurrence of pneumonia, degree of dysphagia using the Dysphagia Severity Scale, patient age, history of smoking, presence of tracheostomy, vital capacity, level of injury, and the American Spinal Injury Association Impairment Scale (AIS) 2 weeks after injury were assessed. Outcomes: Incidence of pneumonia were analyzed. Moreover, the risk factors of pneumonia were evaluated using logistic regression analysis. Results From the 167 individuals who met the criteria, 30 individuals (18%) had pneumonia; in 26 (87%) of these individuals, pneumonia was aspiration related, defined as Dysphagia Severity Scale ≤ 4. The median occurrence of aspiration pneumonia was 11.5 days after injury. A logistic regression analysis revealed that severe AIS and severe Dysphagia Severity Scale scores were significant risk factors of pneumonia after CSCI. Conclusions It was highly likely that the pneumonias following CSCI were related to aspiration based on the Dysphagia Severity Scale. In addition, most of the patients developed aspiration pneumonia within 1 month after injury. Aspiration and severe paralysis were significant risk factors for pneumonia. The treatment of dysphagia in the acute phase should be considered an important indicator to prevent pneumonia.

Cervical spine injuries are uncommon in pediatric trauma patients. Previous studies were often limited by the small numbers of patients available for evaluation. The aim of this study was to determine the incidence and characteristics of pediatric cervical spine injuries at this Level 1 trauma center and to review the authors' experiences with documented cases. This study retrospectively analyzed the clinical records of all pediatric trauma patients with skeletal and/or nonskeletal injuries of the spine that were admitted to this Level 1 trauma center between 1980 and 2004. Those with significant injuries of the cervical spine were identified and included in this study. Pediatric patients were defined as patients younger than the age of 17 years. In addition, they were stratified by age into two study groups: group A included patients aged 8 years or fewer and group B contained patients from the ages of 9 to 16 years. We found 56 pediatric patients with injuries of the cervical spine that met criteria for inclusion. Thirty-one female and 25 male patients with an average age of 8.9 years (range, 1-16 years) sustained significant skeletal and/or nonskeletal injuries of the cervical spine and were entered in this study. Thirty patients (54%) were aged 8 years or fewer and entered into study group A, whereas 26 patients (46%) from the ages of 9 to 16 met criteria for inclusion in study group B. An analysis of data revealed that younger patients (group A) showed significantly more injuries of the upper cervical spine, whereas older children (group B) sustained significantly more injuries of the lower level. Spinal cord injuries without radiographic findings were only found in study group A. In addition, younger children were more likely injured by motor vehicle crashes, whereas older children more commonly sustained C-spine injuries during sports activities. Two-thirds of our patients showed neurologic deficits, and the overall mortality was 28%. The results of our study were similar to several previous reports, underscoring a low incidence (1.2%) and age-related characteristics. Younger children had a predilection for injuries of the upper cervical spine, whereas children in the older age group sustained significantly more injuries of the lower cervical spine. Spinal cord injuries without radiographic abnormalities were only seen in the younger age group. Despite the low incidence of cervical spine injuries in pediatric patients, increased efforts at prevention are demanded because mortality rate (27%) and incidence of neurologic deficits (66%) were dreadfully high in our series.