Cervical Spinal Injury Research Articles

The biomechanical implications of neck position in cervical contusion animal models of SCI.

Large animal contusion models of spinal cord injury are an essential precursor to developing and evaluating treatment options for human spinal cord injury. Reducing variability in these experiments has been a recent focus as it increases the sensitivity with which treatment effects can be detected while simultaneously decreasing the number of animals required in a study. Here, we conducted a detailed review to explore if head and neck positioning in a cervical contusion model of spinal cord injury could be a factor impacting the biomechanics of a spinal cord injury, and thus, the resulting outcomes. By reviewing existing literature, we found evidence that animal head/neck positioning affects the exposed level of the spinal cord, morphology of the spinal cord, tissue mechanics and as a result the biomechanics of a cervical spinal cord injury. We posited that neck position could be a hidden factor contributing to variability. Our results indicate that neck positioning is an important factor in studying biomechanics, and that reporting these values can improve inter-study consistency and comparability and that further work needs to be done to standardize positioning for cervical spinal cord contusion injury models.

Surgical outcome of locked facet in distractive flexion injury of the subaxial cervical spine: Single institution retrospective study.

The optimal surgical treatment for patients suffering from distractive flexion injury of the subaxial cervical spine with a locked facet (LF) is unknown. Closed reduction via an anterior or posterior approach is a treatment option for LF. We examined the surgical outcomes of patients treated for locked facet distractive flexion injury (LF-DFI) in this case series, with a particular emphasis on the surgical approach and reduction maneuver. We retrospectively analyzed the patients with distractive flexion injury of the subaxial cervical spine who underwent surgery at our hospital between November 2006 and April 2021. Patients who did not have facet subluxation or dislocation or those who achieved LF reduction prior to skin incision were excluded from this study. The patients were divided into 2 groups based on their initial approach, anterior or posterior approach. Perioperative clinical outcomes, including the American Spinal Cord Injury Association scale score, radiological changes, and complications were analyzed. This study enrolled 12 patients with LF-DFI. Four and 8 patients underwent the anterior and posterior approaches, respectively. The LF was reduced using an anterior approach with traction between the vertebral bodies in the anterior approach group and using a posterior approach with partial facetectomy in the posterior approach group. The preoperative American Spinal Cord Injury Association scale scores were as follows: A, 1 patient; B, 1 patient; C, 3 patients; D, 4 patients; and E, 3 patients. Nine patients showed no neurologic deterioration after surgery, whereas 2 had an aggravated neurologic status. Postoperatively, patients who underwent posterior open reduction did not exhibit worsened neurologic symptoms, whereas 2 patients who underwent the anterior approach showed worsened neurologic symptoms. At the final follow-up, all patients achieved radiological fusion, and no complications other than neurologic deterioration were identified. In terms of worsening postoperative neurologic status, a posterior approach using partial facetectomy for LF reduction is considered a safer surgical technique than an anterior approach. To avoid iatrogenic intraoperative cord injury, we recommend posterior approach in patients with LF-DFI.

Oral Midodrine as an Adjunct in Rapid Weaning of Intravenous Vasopressor Support in Spinal Cord Injury.

Background Majority of acute cervical spinal cord injury end up requiring long-term stay in intensive care unit (ICU). During the initial few days after spinal cord injury, most patients are hemodynamically unstable requiring intravenous vasopressors. However, many studies have noted that long-term intravenous vasopressors remain the main reason for prolongation of ICU stay. In this series, we report the effect of using oral midodrine in reducing the amount and duration of intravenous vasopressors in patients with acute cervical spinal cord injury. Materials and Methods Five adult patients with cervical spinal cord injury after initial evaluation and surgical stabilization are assessed for the need for intravenous vasopressors. If patients continue to need intravenous vasopressors for more than 24 hours, they were started on oral midodrine. Its effect on weaning of intravenous vasopressors was assessed. Results Patients with systemic and intracranial injury were excluded from the study. Midodrine helped in weaning of intravenous vasopressors in the first 24 to 48 hours and helped in complete weaning of intravenous vasopressors. The rate of reduction was between 0.5 and 2.0 µg/min. Conclusion Oral midodrine does have an effect in reduction of intravenous vasopressors for patients needing prolonged support after cervical spine injury. The real extent of this effect needs to be studied with collaboration of multiple centers dealing with spinal injuries. The approach seems to be a viable alternative to rapidly wean intravenous vasopressors and reduce duration of ICU stay.

In healthy volunteers the Miami-J® cervical collar causes swallow dysfunction. This may increase the risk of aspiration; of particular potential consequence in older people with neck injury

BackgroundIn young healthy volunteers a cervical hard collar has been shown to change swallowing physiology. The risk of aspiration pneumonia increases with age. MethodsIn this open prospective dual-arm controlled trial without randomisation there were 23 patients divided into two cohorts: 11 older (mean age 84) and 12 younger (mean age 25).A series of video fluoroscopy (VF) swallow studies were performed without a cervical collar, followed by the same series of VF with a Miami-J® cervical collar fitted. The Modified Barium Swallow Impairment Profile (MBSImPTM©) and Penetration-Aspiration Scale (PAS) were used to define and score swallow function and level of aspiration without and with the collar fitted. ResultsAn increase in the median MBSImPTM© score amongst all participants in the oral phase of swallow (p = 0.01) and combined oral and pharyngeal phase of swallow (p = 0.006) was seen when volunteers were fitted with the Miami-J® collar, compared to no collar.When wearing the collar deterioration in swallow function and small increases in PAS level were more marked in the older cohort, but these latter findings were not statistically significant. ConclusionsCervical hard collars change swallowing physiology in younger and older volunteers. Whilst we did not measure a statistically significant difference in the PAS level pre- and post- collar wearing, we feel it is important to highlight these changes in swallowing physiology and speculate that with collar use there is a potential risk of aspiration associated with these changes.Potential risk of aspiration should be carefully balanced with the benefit gained from collar use in the management of cervical spine injury (both in conservative and postoperative management). Although this is a small study it is important to highlight an area of concern of particular importance in the older population who have physiological changes to the swallow that occur with age (presbyphagia) and where baseline risk of aspiration is higher.

A pictorial review of imaging findings associated with upper cervical trauma.

The diagnosis of cervical spine injury in the emergency department remains a critical skill of emergency room physicians as well as radiologists. Such diagnoses are often associated with high morbidity and mortality unless readily identified and treated appropriately. Both computed tomography (CT) and magnetic resonance imaging (MRI) often are crucial in the workup of spinal injury and play a key role in arriving at a diagnosis. Unfortunately, missed cervical spine injuries are not necessarily uncommon and often precede detrimental neurologic sequalae. With the increase in whole-body imaging ordered from the emergency department, it is critical for radiologists to be acutely aware of key imaging features associated with upper cervical trauma, possible mimics, and radiographic clues suggesting potential high-risk patient populations. This pictorial review will cover key imaging features from several different imaging modalities associated with upper cervical spine trauma, explore patient epidemiology, mechanism, and presentation, as well as identify confounding radiographic signs to aid in confident and accurate diagnoses.

Epidemiological Profile of traumatic spinal cord injuries in the National Referral Hospital, Bhutan

Introduction: The number of traumatic spinal cord injuries associated with a fracture is on rise which is compounded by rise in number of motor vehicle accidents in the country. The aim of the study was to assess frequency, cause, pattern, and demographic profile of traumatic spinal cord injuries in the Bhutanese population. Methods: A retrospective study was conducted at National Referral Hospital from 2018 to 2020. Hospital records of patients, treated for traumatic spinal cord injury were reviewed. Results: Of the total of 100 patients with traumatic spinal injury admitted during study period, there were 69 males (69%) and 31 females (31%). The mean age was 44.18 years (±16.625 SD). Falls (61%) was most common cause of spine injury followed by road traffic accident (27%). Lumbar spine injury was most common (42%) followed by cervical spine (31%) and thoracic spine (23%) injuries. Of 100 patients with spinal injury 63 patients did not have associated cord injuries while 37% of patients had associated spinal cord injuries and of those with spinal injuries, 20% of them had complete spinal cord injury (SCI) and 17% had incomplete SCI. Regarding treatment, 42% of spine injury patients underwent surgical procedures while 58% were managed conservatively. The mean length of hospital stay after spinal injury was 6.62 days (± 26.06 SD, range 1-215). Conclusions: The study found that most common cause of spine and associated cord injuries were falls followed by road traffic accidents. By collaborating with traffic and road safety division, our study findings have potential to significantly reduce road traffic accidents and enhance preventive measures. Additionally, we can provide valuable education to families regarding rehabilitation and social support, ultimately leading to improved outcomes and better quality of life for individuals living with spinal cord injuries.

Functional Outcome in C2/C3 Fracture Dislocation Managed with Combined Surgical Decompression and Posterior Stabilization

Spinal cord injury is one of the main reasons for permanent paralysis and immobility till now. Spine injury is usually fatal because it involves more than one component, such as discoligamentous misconfiguration, vascular and spinal cord damage. Spine dislocation fracture at the level of C2-3 is rare and usually affects one or two vertebras. Good functional outcome in spine injury is uncommon in which death almost always happens suddenly or is caused by secondary trauma. Emergency room with a cervical spine injury. The patient was pushed by his friends from the side during playtime, causing the neck to hit the corner of a table. The dislocation fracture at the level of C2-3 and spinal cord compression directly caused tetraplegia. The condition was handled with a decompression procedure, spine fusion at the level of C1-4, and posterior stabilization with pedicle screws. A day after the operation, minimal movements were seen in both arms and legs, with motoric strength of 2/2/2/2. The score improved to 4/4/4/4 after two weeks of meds and physiotherapy. The patient started to write again in week 3. The dislocation fracture in this patient caused spinal cord compression. A retropulsion fracture fragment can be displaced to the spinal canal and potentially cause further spinal cord damage. Displacement towards the anterior horn leads to motoric dysfunction. Dislocation fracture at the level of C2-3 hinders neurotransmitter impulse, causing total paralysis on all extremities with intact sensory function. The patient had temporary external stabilization around the neck area while waiting for the procedure. The management concept in cases like this includes affected spinal cord decompression and internal fixation using pedicle screws to ensure fracture stabilization.

Transarticular Fixation Using Bioabsorptive Screws for Cervical Lesions.

Transarticular screw fixation is a method for posterior cervical fixation. It is ergonomic because neither connectors nor rods are needed. Biomechanical studies have shown that its fixation force is not inferior to that of lateral mass screws. More information is needed on the surgical outcome of procedures using bioabsorptive screws. We investigated the long-term surgical and radiological outcomes of posterior cervical decompression and fusion using bioabsorptive screws for transarticular fixation.Of 10 patients who underwent cervical spine transarticular fixation using bioabsorptive screws, nine presented with cervical degenerative spondylosis and one with a traumatic cervical spine injury. The mean postoperative follow-up period was 57.1 months. Transarticular screw fixation was successful in all 10 patients; no intraoperative complications were encountered. Bilateral screw breakage was discovered in a patient with cervical spine instability and associated dystonia due to cerebral palsy; there was no symptom deterioration, facet joint breakage, or instability exacerbation. Facet fusion was obtained in the nine other patients. At the patients' last visit, their clinical symptoms were significantly improved. Whole cervical spine alignment (-4.21 ± 7.2 to -5.2 ± 8.7) and the fused segment angle (mean, -0.1 ± 9.9 to -1.2 ± 13.7) did not significantly worsen postoperatively (mean: -0.1 ± 9.9 to -1.2 ± 13.7). Transarticular fixation using bioabsorptive screws is safe and associated with good long-term outcomes. In patients with exacerbation of local instability after posterior decompression, additional transarticular fixation using bioabsorbable screws is a treatment option.

Concomitant trauma of brain and upper cervical spine: lessons in injury patterns and outcomes.

The literature on concomitant traumatic brain injury (TBI) and traumatic spinal injury is sparse and a few, if any, studies focus on concomitant TBI and associated upper cervical injury. The objective of this study was to fill this gap and to define demographics, patterns of injury, and clinical data of this specific population. Records of patients admitted at a single trauma centre with the main diagnosis of TBI and concomitant C0-C1-C2 injury (upper cervical spine) were identified and reviewed. Demographics, clinical, and radiological variables were analyzed and compared to those of patients with TBI and: (i) C3-C7 injury (lower cervical spine); (ii) any other part of the spine other than C1-C2 injury (non-upper cervical); (iii) T1-L5 injury (thoracolumbar). 1545 patients were admitted with TBI and an associated C1-C2 injury was found in 22 (1.4%). The mean age was 64years, and 54.5% were females. Females had a higher rate of concomitant upper cervical injury (p = 0.046 vs non-upper cervical; p = 0.050 vs thoracolumbar). Patients with an upper cervical injury were significantly older (p = 0.034 vs lower cervical; p = 0.030 vs non-upper cervical). Patients older than 55years old had higher odds of an upper cervical injury when compared to the other groups (OR = 2.75). The main mechanism of trauma was road accidents (RAs) (10/22; 45.5%) All pedestrian injuries occurred in the upper cervical injured group (p = 0.015). ICU length of stay was longer for patients with an upper cervical injury (p = 0.018). Four patients died in the upper cervical injury group (18.2%), and no death occurred in other comparator groups (p = 0.003). The rate of concomitant cranial and upper cervical spine injury was 1.4%. Risk factors were female gender, age ≥ 55, and pedestrians. RAs were the most common mechanism of injury. There was an association between the upper cervical injury group and longer ICU stay as well as higher mortality rates. Increased understanding of the pattern of concomitant craniospinal injury can help guide comprehensive diagnosis, avoid missed injuries, and appropriate treatment.

The Tertiary Survey as a Quality Improvement Initiative in Pediatric Trauma Care.

Patients are at risk of missed or delayed injuries in the setting of multisystem trauma, which may be identified with a tertiary trauma survey (TTS). There is limited literature to support the utilization of a TTS in pediatric trauma population. We aim to assess the impact of the TTS as a quality and performance improvement tool in identifying missed or delayed injuries and improving the quality of care among pediatric trauma population. A retrospective study assessing a quality improvement/performance improvement (QI/PI) project focusing on the administration of tertiary surveys to pediatric trauma patients was conducted at our level 1 trauma center between 08-2020 and 08-2021. Patients with injury severity scores (ISS) greater than 12 and/or an anticipated hospital stay greater than 72hours met inclusion criteria and were included. Of the 535 trauma patients admitted to the pediatric trauma service during the study period, 85 (16%) patients met the criteria and received a TTS. Thirteen unaddressed or undertreated injuries were found in 11 patients: 5 cervical spine injuries, 1 subdural hemorrhage, 1 bowel injury, 1 adrenal hemorrhage, 1 kidney contusion, 2 hematomas, and 2 full thickness abrasions. Following TTS, 13 patients (15%) had additional imaging, which identified 6 of the 13 injuries. The TTS is a valuable quality and performance improvement tool in the comprehensive care of trauma patients. Standardization and implementation of a tertiary survey have the potential to facilitate the prompt detection of injuries and improve the quality of care for pediatric trauma patients. III.

Cervical spine trauma – Evaluating the diagnostic power of CT, MRI, X-Ray and LODOX

BackgroundTraumatic cervical spine (c-spine) injuries account for 10% of all spinal injuries. The c-spine is prone to injury by blunt acceleration/deceleration traumas. The Canadian C-Spine rule and NEXUS criteria guide clinical decision-making but lack consensus on imaging modality when necessary. This study aims to evaluate the sensitivity and specificity of CT, MRI, X-Ray, and, for the first time, LODOX-Statscan in identifying c-spine injuries in patients with blunt trauma and neck pain. MethodsWe conducted a retrospective monocenter cohort study using patient data from the emergency department at Inselspital, Bern, Switzerland's largest level one trauma center. We identified patients presenting with trauma and neck pain during the recruitment period from 01.01.2012 to 31.12.2017. We included all patients that required a radiographic c-spine evaluation according to the NEXUS criteria. Certified spine surgeons reviewed each case, analyzed patient demographics, injury classification, trauma mechanism, and emergency management. The retrospective full case review was established as gold standard to decide whether the c-spine was injured. Sensitivity and specificity were calculated for CT, MRI, LODOX, and X-Ray imaging methods. ResultsWe identified 4996 patients, of which 2321 met the inclusion criteria. 91.3% (n = 2120) patients received a CT scan, 8.9% (n = 206) a MRI, 9.3% (n = 215) an X-ray, and 21.5% (n = 498) a LODOX scan. By retrospective case review, 186 participants were classified as injured. The sensitivity of CT was 88.6% (specificity 99%), and 89.8% (specificity 99.2%) with orthopedic surgeon consultation. MRI had a sensitivity of 88.5% (specificity of 96.9%); highlighting 14 cases correctly diagnosed as injured by MRI and misdiagnosed by CT. Projection radiography (36.4% sensitivity, 95.1% specificity) and LODOX (5.3% sensitivity, 100% specificity) were unsuitable for ruling out spinal injury. ConclusionWhile CT offers high sensitivity for detecting traumatic c-spine injury, MRI holds clinical significance in revealing injuries not recognized by CT in symptomatic patients. LODOX and projection radiography are insufficient for accurately ruling out c-spine injury. For patients with neurological symptoms, we recommend extended MRI use when CT scans are negative.

Facial Fractures and Their Relation to Head and Cervical Spine Injuries in Hospitalized Bicyclists: Erratum

Facial Fractures and Their Relation to Head and Cervical Spine Injuries in Hospitalized Bicyclists: Erratum

Management of Abdominal Gunshot Wounds in Children - Case Report

ABSTRACT Introduction One of the causes of mortality in pediatric population is penetrating abdominal injuries, which can affect several organs. Among all types of abdominal trauma, in gunshot wounds a good prognostic requires prompt diagnosis and treatment. In Romania, there is no specific database on gunshot injuries in the pediatric population, but from various sources, it was found that there are 3 cases (1 case of abdominal injury caused by gunshot in rural area and 2 cases of head and cervical spine injury due to gunshot that took place in urban area). Case presentation A 13-year-old boy is brought to the emergency care unit with a penetrating gunshot wound by ricochet in the left lower abdominal quadrant. Abdominal computed tomography revealed abdominal wall discontinuity in the left iliac fossa with oblique and posterior trajectory and a foreign body in the peritoneal cavity measuring 19/7 mm. Intraoperatory, the projectile was found in the sigmoid colon. Conclusion Penetrating gunshot wounds in pediatric population need adequate investigation and prompt diagnosis despite hemodynamic stability at presentation. Successful management of such a patient depends on the accuracy of the surgical intervention as well as the existence of a multidisciplinary medical team, which helps to prevent significant complications, including death.

청소년 줄넘기 선수들의 참여동기와 신체적 발달요인 탐색

In this study, the motivation to participate in jumping rope exercise and physical development through jumping rope exercise were explored using the Delphi technique and hierarchical decision-making method (AHP). The expert group to achieve the purpose of the study was composed of 28 people with national team experience among the youth, the main age group participating in the jumping rope exercise, through intentional sampling.BR As for the motivation for participation derived through the Delphi technique and decision-making method, invitation from surroundings, intrinsic motivation, and extrinsic motivation were extracted. In invitation from surroundings, the recommendation of the instructor, from intrinsic motivation, health, and from extrinsic motivation, certification was given the highest priority. analyzed as having Sensory development, muscle development, body development, physical fitness development, self-learning, and physical injury were analyzed for physical development factors, and as a result of analyzing the weighted importance, rhythm sense for sensory development, lower body development for muscle development, height growth, and physical strength for body development. Muscle strength improvement in development, principle review in self-learning, and cervical spine injury in physical injury were analyzed to have the highest importance weight.BR

Incidence of Cervical Spine Injuries Among Patients with Maxillofacial Trauma

A substantial portion of cervical spine injuries occurs due to maxillofacial trauma. A delay in the identification of cervical injuries can result in major neurological issues, paralysis, and even death. Therefore, early detection of cervical fractures in patients with maxillofacial trauma is crucial. Aim: The goal of the study is to assess the incidence of cervico-spinal injuries in patients with oral and maxillofacial trauma. Methods: This cross-sectional study was carried out at the Oral and Maxillofacial Surgery department of Mayo Hospital, Lahore for the duration of one year from January 2021 to January 2022. A total of 120 maxillofacial trauma patients treated at the oral surgery department. By using computed tomography, lateral and anteroposterior X-rays; all patients were evaluated for cervical spine injuries. The dependent and independent variables' information was gathered using a structured questionnaire. Results: In 4 (3.3%) patients, cervical spine and maxillofacial injuries were found. Six males and two women were involved in the ten Cervical-spine injuries. The ratio of men to women was 4:1. Despite the low frequency of cervical injuries related with maxillofacial fractures, suitable and precise recommendations for the diagnosis and treatment of these cervical injuries must be adopted to avoid permanent disability and even death. Keywords: Frequency, Maxillofacial trauma, Cervical spine injury

頸髄損傷に合併した経鼻胃管症候群の1例(A case of nasogastric tube syndrome with cervical spinal injury)

経鼻胃管症候群とは，経鼻胃管留置後に咽頭痛，両側声帯の外転麻痺，喉頭浮腫を発症する症候群である。両側声帯麻痺を認めれば気道緊急を要し，しばしば致命的となる。症例は46歳の男性。墜落外傷により当院搬送となった。精査の結果，外傷性くも膜下出血，第6・7頸椎・第6–10胸椎骨折，第6・7頸髄・第6–8胸髄損傷と診断し，入院加療を開始した。第2病日麻痺性イレウスを発症し，経鼻胃管を留置し，減圧加療を開始した。第11病日吸気性喘鳴を聴取し，酸素8L/分投与下でSpO2（経皮的酸素分圧）88%まで低下を認めた。喉頭ファイバースコピー検査で両側声帯麻痺を認め，気道緊急として経口気管挿管を施行し，人工呼吸管理を開始した。第14病日気管切開術を施行した。第39病日声帯麻痺の治癒を確認した。第45病日リハビリテーション目的に転院した。 Nasogastric tube syndrome presents as throat pain, bilateral abductor paralysis of the vocal cords and pharyngeal edema after nasogastric tube placement. This syndrome often requires emergency airway management due to bilateral abductor paralysis and thus can be fatal. A 46–year–old man was transported to the emergency room due to trauma from a fall. We diagnosed traumatic subarachnoid hemorrhage, cervical and thoracic spine fractures, and cervical and thoracic spinal cord injury, and admitted him. On hospital day 2, a nasogastric tube was inserted due to paralytic ileus. On day 11, wheezing was heard on exhalation, and his SpO2 decreased to 88% on oxygen at 8L/min. Laryngeal fiberscopy revealed bilateral vocal cord paralysis, so he was intubated orally. A tracheotomy was performed on day 14. The vocal cord paralysis had healed by day 39, and on day 45, he was transferred to another hospital for rehabilitation. 経鼻胃管症候群とは，経鼻胃管留置後に咽頭痛，両側声帯の外転麻痺，喉頭浮腫を発症する症候群である。両側声帯麻痺を認めれば緊急気道確保を要し，しばしば致命的となる。今回，頸髄損傷を背景として経鼻胃管留置中に両側声帯麻痺を発症した1例を経験したので報告する。 当論文は当院倫理委員会の承諾を受け，個人情報保護法に基づいて匿名化を行っている。また，患者およびその家族から論文の出版に関する同意を得ている。 患 者：49歳の男性。身長180cm，体重91.6kg，BMI 28.3 既往歴：統合失調症 内服薬：アリピプラゾール，フルニトラゼパム，ゾルピデム酒石塩酸，クエチアピンフマル酸塩，アムロジピンベシル酸塩 現病歴：自宅3階からの飛び降りによる転落外傷で受傷した。目撃者が救急要請し，当院救急搬送となった。 来院時現症：気道は開通，呼吸音 清，呼吸様式 正常，呼吸数16/分，SpO2 97%（酸素10L/分 投与下），血圧85/45mmHg，脈拍72/分，Glasgow coma scale E3V5M6，瞳孔径2mm/2mm，対光反射は両側迅速，体温36.2度（腋窩温）であった。 身体所見：後頭部に約20cmの裂創を認めるが活動性出血は認めなかった。右膝・両踵に擦過傷を認めた。徒手筋力テストは両上下肢いずれもMMT 3以上であるが，意思疎通がとれず，詳細な評価は困難であった。持続勃起や肛門括約筋の弛緩は認めなかった。 血液検査：WBC 17,300/µL（Neut 89.4%），Hb 16.4g/dL，Plt 34.9×104/mm3，PT–INR 1.17，Fibrinogen 180mg/dL，APTT 22.2秒，D–dimer 41.21µg/mL 動脈血液ガス分析（酸素マスク10L/分投与下）：pH 7.359，PaCO2 38.0mmHg，PaO2 148.1mmHg，HCO3− 20.9mmol/L，B.E. −4.0mmol/L，lactate 29.2mg/dL 全身CT画像検査：外傷性くも膜下出血，第6・7頸椎棘突起骨折，左第4・5肋骨骨折，第6–8・10胸椎椎体骨折を認めた。 来院時ショックの状態であり，神経原性ショックの可能性を念頭に置いて診療したが，輸液負荷のみで血圧は安定し，入院加療を開始した。血液検査でのWBCおよびD–dimerの上昇は外傷に起因するものと判断した。第2病日，腸蠕動音減弱および腹部レントゲン検査で小腸の拡張を認め，麻痺性イレウスと診断し，減圧目的に20Frの経鼻胃管を留置した。第3病日下肢の筋力低下の訴えがあり，頭部・頸椎・胸椎MRI撮像したところ，T2強調像で第6椎体前面および第6–7頸髄内，第6–8胸髄内の高信号を認め，第6–7頸髄損傷，第6–8胸髄損傷と診断した（Fig. 1）。頸椎カラー装着継続で保存加療の方針とした。リハビリテーション目的の転院調整を開始しようとしたが，第11病日突然の吸気性喘鳴を認め，ボスミン筋肉注射を行うも改善を認めなかった。喉頭ファイバースコピー検査で両側声帯麻痺と診断した（Fig. 2A）。次第にSpO2は低下し，酸素8L/分 投与下にSpO2 88%前後まで酸素化低下を認めた。その時点での動脈血液ガス分析では，pH 7.501，PaCO2 48.8mmHg，PaO2 67.9mmHg，HCO3− 37.3mmol/L，B.E. 12.5mmol/L，lactate 11.8mg/dLと低酸素血症，高二酸化炭素血症を呈していた。経口気管挿管による気道確保を行い，人工呼吸管理を開始した。その後は原因検索を行ったが器質的疾患はいずれも否定的で，経鼻胃管症候群と診断した。麻痺性イレウスは遷延しており，経鼻胃管の抜去は困難であったため，第13病日経鼻胃管を18Frに入れ替えた。長期の気管挿管となることが予想され，第14病日気管切開術を施行した。腸蠕動音正常，腹部レントゲン検査で小腸の拡張の改善を認め，麻痺性イレウスの治癒と判断し，第16病日栄養投与目的に経鼻胃管を10Frに入れ替えた。第39病日喉頭ファイバースコピー検査で声帯麻痺の治癒を確認した（Fig. 2B）。精神状態悪化による昏迷状態となっており，気管切開チューブはスピーチカニューレへの入れ替えにとどめた。第45病日頸椎カラーは装着を継続しリハビリテーション目的に転院した（injury severity score: 17，probability of survival: 0.97972であった）。 Magnetic resonance imaging of the cervical and thoracic vertebrae. MRI（T2）revealed spinal cord injury at the sixth and seventh cervical vertebrae and from the sixth to eighth thoracic vertebrae (red arrow), and 5–mm retropharyngeal hematoma (yellow arrow). Laryngeal fiberscopy. A: Laryngeal fiberscopy showed abnormal abducton of the vocal cords. (during the phase of expiration (left) / inspiration (right)) B: Laryngeal fiberscopy showed recovery of the vocal cords from abductor disorder. (during the phase of expiration (left) / inspiration (right)) Cervical computed tomography (CT). Computed tomography revealed a 6–mm retropharyngeal hematoma (red arrow). 経鼻胃管による咽頭への影響は1939年Wangensteen 1により初めて報告され，その後しばしば症例報告が散見される程度であった。1981年Sofferman 2は，経鼻胃管留置中に咽頭痛，片側あるいは両側の声帯の外転機能不全を来す症候群を経鼻胃管症候群と定義した。診断は，喉頭ファイバースコピー検査で声帯麻痺と診断し，かつ原因となりうる疾患を除外したうえで，臨床的に診断することが多い。発症のタイミングは経鼻胃管を留置して12時間後から抜去2週間後まで多様である 3。 病態は完全には解明されておらず，機序として，①咳嗽や嚥下の際に固定された経鼻胃管と咽頭が垂直方向へ摩擦が起きること，②仰臥位で輪状後部が頸椎側から経鼻胃管により圧迫される，③輪状咽頭筋の収縮が経鼻胃管を脆弱で薄い輪状軟骨後板へ持続的に引き上げる，といったことが推測されている 2。その結果，経鼻胃管による輪状後部への持続的圧迫から結果的に潰瘍形成や感染，虚血が生じ，後輪状披裂筋の機能不全が生じると考えられている 2, 4。糖尿病や低免疫状態，低栄養，加齢に伴う粘膜弾性の低下，パーキンソン症候群，脳血管障害に伴う生理的な嚥下運動の減少による除圧頻度の減少，輪状軟骨レベルでの骨棘突出がリスク因子と言われている 2, 5, 6。経鼻胃管の太さがリスク因子とする報告はない。桜井ら 7による10Frの経鼻胃管を留置していた4例の報告があり，決して細いチューブがリスクを軽減するわけではないと考えられる。またチューブの径が太い方が輪状後部への影響を与える可能性は高く，リスクとなりうると考えるが，今後検討すべき事項である。Friedmanらは，経鼻胃管が声帯部を正中で走行するのは約6%と少ないものの，動物モデルで側方を走行するより正中を走行する方が炎症を生じやすい可能性があると報告している 8。 本症例において，初療時のCT画像や第3病日のMRI画像では声帯自体や輪状軟骨後部を含め声門周囲の直接的な外傷性変化は指摘できなかった。咽頭後間隙の血腫は第1病日のCTで6mm，第3病日のMRIで5mmであった（Fig. 1, 3）。リスク因子は入院後に発症した麻痺性イレウスの影響による低栄養のみであった。経鼻胃管はCT画像で確認する限り，声門部では側方を通過していた。喉頭ファイバースコピー検査の際も側方を通過しているのを確認できた。入院後は頸髄損傷のため，仰臥位での安静時間がほとんどであった。しかし，頸髄損傷で経鼻胃管の留置が必要であった患者はこれまで多く経験しているが，当院で経鼻胃管症候群と診断したのは初めてであり，頸髄損傷などで輪状軟骨レベルでの損傷がある外傷症例での経鼻胃管症候群の報告は，我々が渉猟する限り見られなかった。以上から，本症例では低栄養状態や長期臥床の影響だけでなく，リスク因子として知られている輪状軟骨レベルの骨棘突出と同様の機序で，頸部外傷による咽頭後間隙の血腫・炎症性変化が経鼻胃管による輪状後部への刺激を増強し，炎症や虚血を起こしたのではないかと考えられた。頸髄損傷に偶発的に合併した可能性は否定できないが，椎体前面の外傷性変化が一因となり，経鼻胃管症候群を発症しうることが示唆された。椎体前面に血腫を形成する頸髄損傷の症例には重症度の差がある。軽症例では，通常経口摂取が可能で経鼻胃管が留置される可能性は高くない。一方，重症例では，腹式呼吸や喀痰喀出困難を原因とした呼吸不全に対する気管挿管のタイミングで経鼻胃管が留置されることが多い。その後十分な声帯の評価が行われずに気道確保や気管切開が行われていることが多く，経過中に経鼻胃管症候群を発症していても認知されていない可能性がある。本症例は腹式呼吸を呈するような重症例ではなかったものの，イレウスを発症したことで経鼻胃管が留置され，頸椎前面の外傷性炎症と相まって，経鼻胃管症候群の発症に至った。それに加え，咳嗽減弱や喀痰喀出困難をそれまで認めていなかったという経過から，本症に気づくことができたのではないかと考えた。 治療は経鼻胃管の抜去が必須とされている 9。その他，抗菌薬やPPI，副腎皮質ステロイドなどが投与された報告はあるが，確立した治療法はない。声帯外転障害が改善せず気管カニューレが抜去できないこともある 3。本症例では，治療上経鼻胃管を抜去することは困難であり，まずは経鼻胃管を減圧の治療の障害にならない範囲で細いものに入れ替えたのちに，経鼻胃管を留置している限り短期間での治癒は見込めないと判断し，気管切開術を行った。発症から29日後に声帯麻痺の治癒を確認できた。検索する限り今まで経鼻胃管を抜去せずに経鼻胃管症候群が治癒したという報告は見られなかった。治癒までの期間は長くなるかもしれないが，本症例のように治療上必要であれば経鼻胃管を抜去せずとも治癒する可能性があることが示唆された。 本症例は外傷症例の亜急性期に発生した吸気性喘鳴を契機に，各疾患を除外してから経鼻胃管症候群と診断できた。経鼻胃管症候群は比較的近年に定義された症候群であり，とくに2010年以降の症例報告が増加している 7, 9。これに関しては，経鼻胃管の留置数が著明に増加しているわけではないと考えられることから，発症する頻度が増加したわけではなく，この疾患の概念が認識され始めたことに影響しているものと推測された。対応が遅れると致命的となりうるだけでなく，本疾患を鑑別に入れておかないと経鼻胃管を抜去するなどの対応が遅れ，治癒までの期間が延長しうる。とくに救命・集中治療部門において経鼻胃管は留置されていることの多いデバイスであり，経鼻胃管を留置する際は本合併症に留意して管理を行う必要がある。 椎体前面の外傷性変化が一因になったと考えられた経鼻胃管症候群の1例を経験した。経鼻胃管はよく留置されるデバイスであり，両側声帯麻痺を発症した場合，緊急気道確保を行うとともに，経鼻胃管症候群を鑑別に挙げて治療を行う必要がある。 本論文の要旨は第122回近畿救急医学研究会（2021年，大阪）で発表した。 本稿のすべての著者に規定された利益相反はない。

A Rare Case of Traumatic Cervicogenic Exophthalmos: A Case Report (P7-1.012)

<h3>Objective:</h3> NA <h3>Background:</h3> A cervical spine injury can cause headaches, vertigo, dizziness, tinnitus, and rarely unilateral exophthalmos. The relationship between cervical spine injury and reflex sympathetic dystrophy (RSD) is well established to explain the symptoms. Here, we present a patient developing bilateral exophthalmos after a fall with cervical spine injuries. Although unilateral cervicogenic exophthalmos has been suggested in the literature, we describe the first case of bilateral cervicogenic exophthalmos after a cervical spine injury. <h3>Design/Methods:</h3> NA <h3>Results:</h3> <h3>Case Report:</h3> A 53-year-old man presented after a fall at home. Trauma workup revealed hyperextension injury, anterior longitudinal ligament (ALL) disruption, and cord edema from C3-C6. After admission, the patient had quadriplegia and significant bilateral exophthalmos. He had urgent open reduction and internal fixation (ORIF) of C4-C5 and C5-C6, discectomies, and fusion with the insertion of plates and screws. After the surgery, his exophthalmos improved significantly. Unfortunately, multiple attempts to wean from the ventilator were unsuccessful. The patient’s family elected for compassionate extubation and discharge to hospice services per his living will, where he passed away. <h3>Conclusions:</h3> A cervical spine injury is a very rare cause of exophthalmos. Two case reports were found online for unilateral exophthalmos related to spondylosis of the cervical spine, which is thought to be caused by RSD, a chronic condition. Here we describe a patient presenting with significant bilateral exophthalmos secondary to the acute traumatic cervical spine. The patient’s bilateral exophthalmos improved significantly after his cervical spine surgery. To the best of our knowledge, ours is among the first few case reports of acute ‘traumatic cervicogenic exophthalmos.’ Further speculation is that the exophthalmos is probably associated with sympathetic nervous system hyperactivity related to cervical spine injury. <b>Disclosure:</b> Dr. Su has nothing to disclose. Dr. Zahra has nothing to disclose. Dr. Singh has nothing to disclose. Dr. Varade has nothing to disclose.

Evolution of patient-reported outcome measures, 1, 2, and 5 years after surgery for subaxial cervical spine fractures, a nation-wide registry study

BACKGROUND CONTEXTA longer duration of patient follow up arguably provides more reliable data on the long-term effects of a treatment. However, the collection of long-term follow up data is resource demanding and often complicated by missing data and patients being lost to follow up. In surgical fixation for cervical spine fractures, data are lacking on the evolution of patient reported outcome measures (PROMs) beyond 1-year of follow up. We hypothesized that the PROMs would remain stable beyond the 1-year postoperative follow up mark, regardless of the surgical approach. PURPOSETo assess the trends in the evolution of patient-reported outcome measures (PROMs) at 1, 2-, and 5-years following surgery in patients with traumatic cervical spine injuries. STUDY DESIGNNation-wide observational study on prospectively collected data. PATIENT SAMPLEIndividuals treated for subaxial cervical spine fractures with anterior, posterior, or combined anteroposterior approaches, between 2006 and 2016 were identified in the Swedish Spine Registry (Swespine). OUTCOME MEASURESPROMs consisting of EQ-5D-3Lindex and the Neck Disability Index (NDI) were considered. METHODSPROMs data were available for 292 patients at 1 and 2 years postoperatively. Five-years PROMs data were available for 142 of these patients. A simultaneous within-group (longitudinal) and between group (approach-dependent) analysis was performed using mixed ANOVA. The predictive ability of 1-year PROMs was subsequently assessed using linear regression. RESULTSMixed ANOVA revealed that PROMs remained stable from 1- to 2-years as well as from 2- to 5-years postoperatively and were not significantly affected by the surgical approach (p<0.05). A strong correlation was found between 1-year and both 2- and 5-years PROMs (R>0.7; p<0.001). Linear regression confirmed the accuracy of 1-year PROMs in predicting both 2- and 5-years PROMs (p<0.001). CONCLUSIONPROMs remained stable beyond 1-year of follow up in patients treated with anterior, posterior, or combined anteroposterior surgeries for subaxial cervical spine fractures. The 1-year PROMs were strong predictors of PROMs measured at 2, and 5 years. The 1-year PROMs were sufficient to assess the outcomes of subaxial cervical fixation irrespective of the surgical approach.

Ultrasonography is an effective tool for the evaluation of traumatic vertebral artery injuries distal to fourth cervical vertebra in the emergency room

BackgroundThis study aimed to determine the feasibility of ultrasonography in the assessment of cervical vertebral artery (VA) injury as an alternative to computed tomography angiography (CTA) in the emergency room.MethodsWe analyzed 50 VAs from 25 consecutive patients with cervical spine injury that had been admitted to our emergency room. Ultrasonography and CTA were performed to assess the VA in patients with cervical spine injury. We examined the sensitivity and specificity of ultrasonography compared with CTA.ResultsAmong these VAs, six were occluded on CTA. The agreement between ultrasonography and CTA was 98% (49/50) with 0.92 Cohen's Kappa index. The sensitivity, specificity, and positive and negative predictive values of ultrasonography were 100%, 97.7%, 85.7%, and 100%, respectively. In one case with hypoplastic VA, the detection of flow in the VA by ultrasonography differed from detection by CTA. Meanwhile, there were two cases in which VAs entered at C5 transverse foramen rather than at C6 level. However, ultrasonography could detect the blood flow in these VAs.ConclusionsUltrasonography had a sensitivity of 100% compared with CTA in assessment of the VA. Ultrasonography can be used as an initial screening test for VA injury in the emergency room.

Pediatric cervical spine clearance: A 10-year evaluation of multidetector computed tomography at a level 1 pediatric trauma center.

Efficient and accurate evaluation of the pediatric cervical spine (c-spine) for both injury identification and posttraumatic clearance remains a challenge. We aimed to determine the sensitivity of multidetector computed tomography (MDCT) for identification of cervical spine injuries (CSIs) in pediatric blunt trauma patients. A retrospective cohort study was conducted at a level 1 pediatric trauma center from 2012 to 2021. All pediatric trauma patients age younger than 18 years who underwent c-spine imaging (plain radiograph, MDCT, and/or magnetic resonance imaging [MRI]) were included. All patients with abnormal MRIs but normal MDCTs were reviewed by a pediatric spine surgeon to assess specific injury characteristics. A total of 4,477 patients underwent c-spine imaging, and 60 (1.3%) were diagnosed with a clinically significant CSI that required surgery or a halo. These patients were older, more likely to be intubated, have a Glasgow Coma Scale score of <14, and more likely to be transferred in from a referring hospital. One patient with a fracture on radiography and neurologic symptoms got an MRI and no MDCT before operative repair. All other patients who underwent surgery including halo placement for a clinically significant CSI had their injury diagnosed by MDCT, representing a sensitivity of 100%. There were 17 patients with abnormal MRIs and normal MDCTs; none underwent surgery or halo placement. Imaging from these patients was reviewed by a pediatric spine surgeon, and no unstable injuries were identified. Multidetector computed tomography appears to have 100% sensitivity for detecting clinically significant CSIs in pediatric trauma patients, regardless of age or mental status. Forthcoming prospective data will be useful to confirm these results and inform recommendations for whether pediatric c-spine clearance can be safely performed based on the results of a normal MDCT alone. Diagnostic Tests or Criteria; Level IV.