Concomitant Cervical Spine Injury Research Articles

Computed Tomographic Scan for Head Injury Patients: Any Justification for Adapting Routine Cranio-Cervical Examination Irrespective of Clinical Severity?

This study aimed to assess the prevalence of concomitant cervical spine and head injury at our University Teaching Hospital in Nigeria and attempted to justify examining patients' head and cervical spine using computed tomography (CT) scan at presentation irrespective of the head injury severity by clinical assessment using Glasgow Coma Scale (GCS). All eligible patients, 1-80 years of age who presented with head injuries in the accident and emergency (A&E) unit during the study period, were included if they satisfied the inclusion criteria. Post-resuscitation GCS was assessed clinically, and head and cervical spine injury (CSI) were observed radiologically on cranio-cervical CT scan for all patients. The presence of cervical spine fractures, subluxation or dislocation was considered a confirmation of CSI. There were 143 patients with head injuries studied; 90.2% of them were males. The mean age of the patients was 28.87 ± 15.93 years. The most common cause of injury was road traffic accidents in 110 (76.90%). The prevalence of CSI was 11.2%. Majority of the patients with CSI in this study (56.25%) had a mild head injury, 25% had a moderate head injury, and 18.75% had a severe head injury. The lower cervical spine was the most frequently injured segment in this study, involving 10 patients. Multi-level cervical vertebral body fractures of C3 to C6 were the most common form of CSI in this segment. The prevalence of concomitant cervical spine and head injury was significant in this study. This was confirmed among study subjects with a clinical diagnosis of mild-to-moderate head injury as compared with moderate-to-severe head injury. Therefore, all patients who sustained a head injury irrespective of severity are required to have a complete and rapid evaluation of the cervical spine.

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

Bicyclists are vulnerable road users. The authors aimed to characterise facial fractures and their association with head and neck injuries in bicyclists admitted to a Scandinavian Level 1 trauma center with a catchment area of ~3 million inhabitants. Data from bicycle-related injuries in the period 2005 to 2016 were extracted from the Oslo University Hospital trauma registry. Variables included were age; sex; date of injury; abbreviated injury scale (AIS) codes for facial skeletal, head and neck injuries; and surgical procedure codes for treatment of facial fractures. Anatomical injury was classified according to AIS98. A total of 1543 patients with bicycle-related injuries were included. The median age was 40 years (quartiles 53, 25), and 1126 (73%) were men. Overall, 652 fractures were registered in 339 patients. Facial fractures were observed in all age groups; however, the proportion rose with increasing age. Bicyclists who suffered from facial fractures more often had a concomitant head injury (AIS head >1) than bicyclists without facial fractures (74% vs. 47%), and the odds ratio for facial fracture(s) in the orbit, maxilla and zygoma were significantly increased in patients with AIS head >1 compared to patients with AIS head=1. In addition, 17% of patients with facial fractures had a concomitant cervical spine injury versus 12% of patients without facial fractures. This results showed that facial fractures were common among injured bicyclists and associated with both head and cervical spine injury. Thus, a neurological evaluation of these patients are mandatory, and a multidisciplinary team including maxillofacial and neurosurgical competence is required to care for these patients.

Pattern of Facial Fractures and Its Association with a Cervical Spine Injury in a Tertiary Hospital in Jordan.

Background Facial fractures can be accompanied by serious and life-threatening injuries such as cervical spine injury (CSI), which can lead to serious consequences if misdiagnosed. Objective To assess the patterns of maxillofacial fractures and to explore the association between these fractures and cervical spine injuries (CSIs) in patients with a traumatic facial injury. Methods A retrospective analysis was conducted on the data of the subjects who were admitted to the King Abdullah University Hospital (KAUH) and had a maxillofacial fracture in the period from January 2017 through December 2020. Stepwise binary logistic regression analysis was conducted to find the variables which are significantly and independently associated with CSIs. Results A total of 394 maxillofacial fractures were reported for a total of 221 subjects. The mandible was the most common site of the reported fractures (41.88%). The majority of the subjects had associated injuries (70.6%), of which 82.7% were CSIs. The most common type of the CSIs was the vertebral fracture (52%). Increased age (OR = 1.543, P < 0.05), having a mandibular fracture (OR = 4.382, P < 0.01), and having a maxillary fracture (OR = 3.269, P < 0.05) were significantly associated with the presence of CSI. Conclusion The current study revealed that the most common type of facial fracture occurred in the mandible area, and CSI was the most common fracture-associated injury (82.7%). Increased age and having mandibular or maxillary fracture were associated with an increased risk of developing CSI. Therefore, it is necessary to rule out the presence of concomitant CSI during the emergency management of maxillofacial fractures, particularly for elderly patients and those with mandibular or maxillary fractures.

Frequency of Cervical Spine Injuries in Pediatric Craniomaxillofacial Trauma

In pediatric patients with craniomaxillofacial (CMF) trauma, evaluation for cervical spine injury (CSI) is critical, but there are no studies investigating CSI in this unique population. The aim of this study was to measure the frequency of CSI in the pediatric CMF fracture population. A retrospective cohort study of all pediatric patients who presented to the Johns Hopkins Hospital Emergency Department (Baltimore, MD) with CMF fractures were examined for concurrent CSIs. Patient charts were reviewed for mechanism of injury, type and level of CSI, type and location of CMF fracture patterns, and overall outcome. Data were analyzed for correlation and statistical relevance. A total of 2,966 pediatric patients (1,897 boys [64.0%]; age range, 0 to 15yr; average age, 7±4.73yr) were identified from 1990 to 2010 to have CMF fractures. Of these patients, only 5 children were found to have concomitant CSIs (frequency, 0.169%). The frequency of CSI in patients with CMF fracture and deciduous, mixed, and permanent dentition was 0, 0.307, and 0.441%, respectively. Of the 5 identified cases, 4 had concomitant middle-third facial skeletal fracture, 4 had concomitant upper-third cranial skeletal fracture, and 2 had concomitant lower-third cranial skeletal fracture. CSIs in pediatric patients with CMF fracture are rare (frequency, 0.169%); this is considerably lower than the reported ranges in adults (3.69 to 24%). No child with deciduous dentition was found to have a CSI. The lack of CSI in deciduous patients with CMF fracture could be explained by the anatomic differences between pediatric and adult cervical spines and supports conservative imaging for children in this age group (level of evidence, III).

Investigating the time-lapsed effects of rigid cervical collars on the dimensions of the internal jugular vein.

Protocol advocates the use of rigid cervical collars (RCCs) in head trauma patients as they are at risk of concomitant cervical spine injury. Literature has shown RCCs to be a potential cause of venous outflow obstruction, changing internal jugular vein (IJV) cross-sectional area (CSA), and raising intracranial pressure (ICP). This study aims to investigate the effects of applying a RCC, for a period of four hours, on the dimensions of the IJV, in healthy participants. Seventeen participants (nine male, eight female) took part in this study. Circumference and CSAs of the IJV were measured bilaterally by a single observer using a GE LOGIQ e ultrasound system. Measurements were taken pre-RCC application, immediately after, every hour over four hours, and five minutes postcollar removal. The CSA of the IJV was 8.3 ±6.0 mm2 pre-RCC application. The CSA of the IJV doubled (18.92 ±10.55 mm2 ) after four hours and decreased back to 9.36 ±6.8 mm2 five minutes postcollar removal. The circumference of the IJV was 17.29 ±6.03 mm pre-RCC application, increasing to 20.34 ±5.59 mm by the end of the fourth hour and returning to 16.14 ±5.16 mm five minutes postcollar removal. Related-samples Friedman's ANOVA test showed statistically significant differences for both left and right CSAs and circumferences of the IJV measured across the four hours (P-value<0.05). Ultrasound assessment of CSA of the IJV may correlate with changes in ICP. Further studies may provide insight into the effects of collar design, and guide future trauma protocol to minimize intracranial pressure fluctuations. Clin. Anat. 32:196-200, 2019. © 2018 Wiley Periodicals, Inc.

Cervical spine fractures associated with maxillofacial trauma: A 3-year-long study in the Greek population

BackgroundMaxillofacial fractures have been recognized as high risk trauma for concomitant cervical spine or spinal cord injury. ObjectiveTo investigate the incidence of concomitant cervical spine fractures (CSF) in patients with maxillofacial trauma and elucidate their relationship, guiding diagnosis and pointing their implications in maxillofacial trauma repair. Material and MethodsAn analysis of 432 patients with maxillofacial fractures, treated at the Department of Oral and Maxillofacial Surgery of the “KAT” General Hospital of Attica during a three-year-long period, was conducted to investigate concomitant CSF. Results22 patients or 5.1% (14 male/8 female, mean age 39.81 years) sustained a total of 29 concomitant CSF. In 77.3% of the cases the injury mechanism was motor vehicle accidents. The most frequent levels of CSF were C6–C7 (55.17%) and C1–C2 (27.58%). Regarding the type/site of maxillofacial fractures, 5 patients (22.73%) had sustained isolated zygomatoorbital, 5 (22.73%) isolated mandibular and 12 (54.54%) combined fractures. Concomitant injuries (i.e. intracranial hemorrhage, cerebral concussion, etc) were registered in 14 patients; additional thoracic/lumbar spine fractures in 5. Hospital stay ranged from 6 to 86 days (mean 27.6 days). ConclusionsMaxillofacial surgeons should be aware of the relationship between CSF and maxillofacial fractures, having implications in their patients' treatment.

Routine cervical spine immobilisation is unnecessary in patients with isolated cerebral gunshot wounds: A South African experience.

Routine immobilisation of the cervical spine in trauma has been a long established practice. Very little is known in regard to its appropriateness in the specific setting of isolated traumatic brain injury secondary to gunshot wounds (GSWs). A retrospective study was conducted over a 5 year period (January 2010 to December 2014) at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa in order to determine the actual incidence of concomitant cervical spine injury (CSI) in the setting of isolated cerebral GSWs. During the 5 year study period, 102 patients were included. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-eight per cent of the injuries were secondary to low velocity GSWs. Twenty-seven (26%) patients had cervical collar placed by the Emergency Medical Service. The remaining 75 patients had their cervical collar placed in the resuscitation room. Fifty-five (54%) patients had a Glasgow Coma Scale (GCS) of 15 and underwent plain radiography, all of which were normal. Clearance of cervical spine based on normal radiography combined with clinical assessment was achieved in all 55 (100%) patients. The remaining 47 patients whose GCS was <15 all underwent a computed tomography (CT) scan of their cervical spine and brain. All 47 CT scans of the cervical spine were normal and there was no detectable bone or soft tissue injury noted. Patients who sustain an isolated low velocity cerebral GSW are highly unlikely to have concomitant CSI. Routine cervical spine immobilisation is unnecessary, and efforts should be directed at management strategies aiming to prevent secondary brain injury. Further studies are required to address the issue in the setting of high velocity GSWs.

Open reduction and external fixation of a condylar fracture with concomitant cervical spine injury

Open reduction and external fixation of a condylar fracture with concomitant cervical spine injury

Maxillofacial trauma - Underestimation of cervical spine injury.

Undiagnosed cervical spine injury can have devastating results. The aim of this study was to analyse patients with primary maxillofacial trauma and a concomitant cervical spine injury. It is hypothetised that cervical spine injury is predictable in maxillofacial surgery. A monocentric clinical study was conducted over a 10-year period to analyse patients with primary maxillofacial and associated cervical spine injuries. Demographic data, mechanism of injury, specific trauma and treatments provided were reviewed. Additionally a search of relevant international literature was conducted in PubMed by terms "maxillofacial" AND "cervical spine" AND "injury". Of 3956 patients, n=3732 (94.3%) suffered from craniomaxillofacial injuries only, n=174 (4.4%) from cervical spine injuries only, and n=50 (1.3%) from both craniomaxillofacial and cervical spine injuries. In this study cohort the most prevalent craniofacial injuries were: n=41 (44%) midfacial and n=21 (22.6%) skull base fractures. Cervical spine injuries primarily affected the upper cervical spine column: n=39 (58.2%) vs. n=28 (41.8%). Only in 3 of 50 cases (6%), the cervical spine injury was diagnosed coincidentally, and the cervical spine column was under immobilised. The operative treatment rate for maxillofacial injuries was 36% (n=18), and for cervical spine injuries 20% (n=10). The overall mortality rate was 8% (n=4). The literature search yielded only 12 papers (11 retrospective and monocentric cohort studies) and is discussed before our own results. In cases of apparently isolated maxillofacial trauma, maxillofacial surgeons should be aware of a low but serious risk of underestimating an unstable cervical spine injury.

A review of cervical spine injury associated with maxillofacial trauma at a UK tertiary referral centre.

The aim of this study was to determine the incidence and patterns of cervical spine injury (CSI) associated with maxillofacial fractures at a UK trauma centre. A retrospective analysis was conducted of 714 maxillofacial fracture patients presenting to a single trauma centre between 2006 and 2012. Of the 714 maxillofacial fracture patients, 2.2% had associated CSI including a fracture, cord contusion or disc herniation. In comparison, 1.0% of patients without maxillofacial trauma sustained a CSI (odds ratio: 2.2, p=0.01). The majority (88%) of CSI cases of were caused by a road traffic accident (RTA) with the remainder due to falls. While 8.8% of RTA related maxillofacial trauma patients sustained a CSI, only 2.0% of fall related patients did (p=0.03, not significant). Most (70%) of the CSIs occurred at C1/C2 or C6/C7 levels. Overall, 455, 220 and 39 patients suffered non-mandibular, isolated mandibular and mixed mandibular/non-mandibular fractures respectively. Their respective incidences of CSI were 1.5%, 1.8% and 12.8% (p=0.005, significant). Twelve patients with concomitant CSI had their maxillofacial fractures treated within twenty-four hours and all were treated within four days. The presence of maxillofacial trauma mandates exclusion and prompt management of cervical spine injury, particularly in RTA and trauma cases involving combined facial fracture patterns. This approach will facilitate management of maxillofacial fractures within an optimum time period.

The effect of various types of motorcycle helmets on cervical spine injury in head injury patients: a multicenter study in Taiwan.

Introduction. The relationship between cervical spine injury (CSI) and helmet in head injury (HI) patients following motorcycle crashes is crucial. Controversy still exists; therefore we evaluated the effect of various types of helmets on CSI in HI patients following motorcycle crashes and researched the mechanism of this effect. Patients and Methods. A total of 5225 patients of motorcycle crashes between 2000 and 2009 were extracted from the Head Injury Registry in Taiwan. These patients were divided into case and control groups according to the presence of concomitant CSI. Helmet use and types were separately compared between the two groups and the odds ratio of CSI was obtained by using multiple logistic regression analysis. Results. We observed that 173 (3.3%) of the HI patients were associated with CSI. The HI patients using a helmet (odds ratio (OR) = 0.31, 95% confidence interval (CI) = 0.19−0.49), full-coverage helmet (0.19, 0.10−0.36), and partial-coverage helmet (0.35, 0.21−0.56) exhibited a significantly decreased rate of CSI compared with those without a helmet. Conclusion. Wearing full-coverage and partial-coverage helmets significantly reduced the risk of CSI among HI patients following motorcycle crashes. This effect may be due to the smooth surface and hard padding materials of helmet.

Cervical spine injury associated with facial trauma.

Maxillofacial fractures carry a high risk of associated cervical spine injury. Concomitant cervical spine injury in trauma patients may influence airway management, choice of diagnostic imaging, surgical approach, and timing of repair of associated facial fractures.

Risk factors for cervical spine injury among patients with traumatic brain injury

Background:Diagnosis of cervical spine injury (CSI) is difficult in patients with an altered level of consciousness as a result of a traumatic brain injury (TBI). Patients with TBI and older adults are at increased risk for CSI. This study examined the various risk factors for CSI among trauma patients with TBI and whether adults who were older (≥55 years) were at higher risk for CSI when they sustained a fall-related TBI.Materials and Methods:Data used was the 2007 National Trauma Data Bank (NTDB), National Sample Project (NSP) for adults who sustained a TBI. This dataset contains 2007 admission records from 82 level I and II trauma centers. Logistic regression was used to identify potential risk factors for CSI and to test for interaction between age and injury mechanism. Additional model variables included gender, race, Glasgow Coma Score, multiple severe injuries, hypotension and respiratory distress.Results:An analysis of the NTDB NSP identified 187,709 adults with TBI, of which 16,078 were diagnosed with a concomitant CSI. In motor vehicle traffic injuries, the older age group had significantly higher odds of CSI (odds ratio [OR] = 1.26 [1.15-1.39]). In fall-related injuries the older age group did not have a higher odds of CSI compared to the younger age group. Skull/face fracture, other spine fracture/dislocation, upper limb injury, thorax injury, and hypotension were significantly associated with CSI. Pelvic injuries had an inverse association with CSI (OR = 0.60 [0.54-0.67]). Black had significantly higher odds of CSI compared to Whites (OR = 1.25 [1.07-1.46]).Conclusion:The identification of associated injuries and factors may assist physicians in evaluating CSI in patients with TBI.

Poster 105: Cervical Spine Injuries Associated With Mandibular Trauma

Cervical spine fractures are a severe injury associated with high morbidity and mortality. Due to the tragic consequences of a missed cervical spine injury, maxillofacial surgeons must be acutely aware of the mechanisms most likely to result in cervical injury when evaluating patients with mandibular trauma.1 Past studies have investigated this association and reported a prevalence of 0.0 to 8.2%.2 This study examines the relationship between mandibular fractures and concomitant cervical spine injury at an urban trauma center.

Clinical Characterization of Comatose Patients With Cervical Spine Injury and Traumatic Brain Injury

Reports on the risk factors for combined craniocervical spine injury in comatose patients are rare. The incidence of concomitant cervical injury in comatose patients with traumatic brain injury (TBI) was determined herein. One thousand twenty-six comatose patients with TBI were examined. The clinical characteristics of combined craniocervical trauma were documented, including type and location of cervical injury, occurrence of hypotension, and dyspnea. Seventy-one patients (6.92%) sustained cervical spine injury. The most common injury region included the upper cervical segments, demonstrated in 37 (52.11%) of 71 patients. Of the 71 patients who sustained combined craniocervical spine injury, 42 (59.15%) had hypotension, including 26 (36.62%) with dyspnea. With regard to the association between the severity of TBI and the incidence of the cervical injury, a significant difference was apparent between patients with an initial Glasgow Coma Scale (GCS) score of 3-5 and those with an initial GCS score of 9-12 (11.62% compared with 4.03%, p < 0.01). Regarding the relationship between the mechanism of injury and the occurrence of cervical spine injury, cervical spine injury was associated at a significantly higher incidence with motorcycle accident-related head trauma as compared with non motorcycle accident-related trauma (10.32% vs. 4.68%, p < 0.01). Patients who sustained TBI as a result of motorcycle accidents and those exhibiting a lower GCS score are at the highest risk for concomitant cervical spine injury.

Poster 265: Somatosensory and Motor Evoked Potential Application in Maxillofacial Trauma: Monitoring of Spinal Cord Function During Mandibular Fracture Repair With Concomitant Cervical Spine Injury

Poster 265: Somatosensory and Motor Evoked Potential Application in Maxillofacial Trauma: Monitoring of Spinal Cord Function During Mandibular Fracture Repair With Concomitant Cervical Spine Injury

6. Doctor on the sidelines

Effectively managing on-field emergencies is the most important role of the doctor on the sidelines. Pre-event preparation is essential and should include a formulated plan for dealing with emergencies and access to emergency equipment such as a stretcher and a bag and mask. Game day injuries should be assessed by adhering as closely as possible to a normal clinical consultation, with a proper history and examination being performed for all injuries. The athlete with an on-field head injury should be treated as having a concomitant cervical spine injury until proven otherwise. Athletes with any symptoms after head injury should be comprehensively and continuously assessed. Return-to-play decisions are made by balancing the risk of injury recurrence, the potential severity of injury recurrence and the benefits of returning to the field (which are higher at elite than amateur level). There is currently a shortage of doctors willing to cover sports events in Australia, which is partially explained by inadequate remuneration, inadequate facilities provided at venues, inadequate training opportunities in sports medicine, and fear of the medicolegal consequences in taking on the role as a team doctor.

Blunt cervical spine injuries in Scotland 1995–2000

Background: In the Accident and Emergency Department, the management of patients who have sustained head injuries (HI) is often made more complicated by the suspicion of a cervical spine injury (CSI). This study aimed to evaluate the incidence of CSI in patients sustaining blunt head injuries in a Scottish population. Methods: Retrospective analysis of prospectively collected data for a 5-year period from the Scottish Trauma Audit Group (STAG) database. Logistic regression and other comparisons were used to investigate the relationship between Glasgow coma score/scale (GCS) and the incidence of CSI. Results: A total of 5154 patients met the criteria for the study and 273 of the HI patients had associated CSI giving an overall incidence of 5.3%. Patients presenting with GCS of 3 were almost three times more likely to have a CSI compared to patients with an initial GCS of 4 or more (12.5% versus 4.4%, χ 2=62.9, d.f.=1, P<0.001). When patients with GCS of 3 were excluded, there was no evidence of an increase in the incidence of CSI with a lower GCS (logistic regression χ 2=0.09, d.f.=1, P=0.75). Conclusion: The risk of CSI in patients with blunt head trauma and an admission GCS of ≥4 does not decrease as GCS increases. Patients with blunt head injuries who present with a GCS of 3 are much more likely to have a concomitant CSI. The overall incidence of 5.3% compares with published series from other countries.

Effect of cervical hard collar on intracranial pressure after head injury.

Patients suffering head trauma are at high risk of having a concomitant cervical spine injury. A rigid cervical collar is usually applied to each patient until spinal stability is confirmed. Hard collars potentially cause venous outflow obstruction and are a nociceptive stimulus, which might elevate intracranial pressure (ICP). This study tested the hypothesis that application of a hard collar is associated with an increase in ICP. A prospective series of 10 head-injured patients with a postresuscitation Glasgow coma scale score of nine or less had ICP measurements before and after cervical hard collar application. Nine out of 10 patients had a rise in ICP following application of the collar. The difference in pre- and postapplication ICP was statistically significant (P < 0.05). Early assessment of the cervical spine in head-injured patients is recommended to minimize the risk of intracranial hypertension related to prolonged cervical spine immobilization with a hard collar.

Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics.

Diagnosing and managing cervical spine trauma in head-injured patients is problematic due to an altered level of consciousness in such individuals. The reported incidence of cervical spine trauma in head-injured patients has generally ranged from 4 to 8%. In this retrospective study the authors sought to define the incidence of cervical injury in association with moderate or severe brain injury, emphasizing the identification of high-risk patients. The study included 447 consecutive moderately (209 cases) or severely (238 cases) head injured patients who underwent evaluation at two Level 1 trauma centers over a 40-month period. Of the 447 patients, 24 (5.4%) suffered a cervical spine injury (17 men and seven women; mean age 39 years; median Glasgow Coma Scale [GCS] score of 6, range 3-14). Of these 24 patients, 14 (58.3%) sustained spinal cord injuries (SCIs), 14 sustained injuries in the occiput-C3 region, and 10 underwent a stabilization procedure. Of the 14 patients with SCIs, nine experienced an early hypotensive and/or hypoxic insult. Regarding the mechanism of injury, cervical injuries occurred in 21 (8.2%) of 256 patients involved in motor vehicle accidents (MVAs), either as passengers or pedestrians, compared with three (1.6%) of 191 patients with non-MVA-associated trauma (p < 0.01). In the subset of 131 MVA passengers, 13 (9.9%) sustained cervical injuries. Patients with an initial GCS score less than or equal to 8 were more likely to sustain a cervical injury than those with a score higher than 8 (odds ratio [OR] 2.77, 95% confidence interval [CI] = 1.11-7.73) and were more likely to sustain a cervical SCI (OR 5.5, 95% CI 1.22-24.85). At 6 months or more postinjury, functional neurological recovery had occurred in nine patients (37.5%) and eight (33.3%) had died. Head-injured patients sustaining MVA-related trauma and those with an initial GCS score less than or equal to 8 are at highest risk for concomitant cervical spine injury. A disproportionate number of these patients sustain high cervical injuries, the majority of which are mechanically unstable and involve an SCI. The development of safer and more rapid means of determining cervical spine integrity should remain a high priority in the care of head-injured patients.