Multilevel Injury Research Articles

Management of Self-Inflicted Nonaccidental Amputations of the Upper Extremity: Systematic Review

Clinicians assessing patients with deliberate self-inflicted amputations face a problem of whether or not to replant. The objective of this study was to summarize the literature on this topic and provide recommendations regarding the acute management of patients following self-inflicted amputations in the upper extremity. Two reviewers searched four databases using the keywords "Upper extremity," "Amputation," and "Self-Inflicted." The reviewers systematically screened and collected data on publications reporting cases of self-inflicted upper-extremity amputations. The findings then were summarized in a narrative fashion. Twenty-four studies were included. Twenty-nine cases of self-inflicted upper-extremity amputations were reported. There were 25 unilateral and four bilateral extremity amputations. Amputations were most commonly at the hand/wrist (18 patients) and forearm level (6 patients). The amputations were most commonly performed with a saw (9 patients) or a knife (8 patients). Reasons for amputation included psychosis (10 cases), suicide attempt (7 cases), depression (5 cases), and body integrity identity disorder (four cases). Fifteen replantations were performed; all were successful. Reasons for not pursuing replantation were related to injury factors (ie, multilevel injury, prolonged ischemia, damaged part) rather than patient-level factors. Two patients with replantable extremities declined replantation, both of whom had body integrity identity disorder. Of the patients who underwent replantation, none expressed regret. The literature shows that patients experiencing psychosis or depression committed self-harm during an acute psychiatric decompensation, and once medically and psychiatrically stabilized, expressed satisfaction with their replanted limb. Surgeons should not consider psychiatric decompensation a contraindication to replantation and should be aware of patients with body integrity identity disorder who consciously may elect to undergo revision amputation. When presented with patients experiencing psychiatric decompensation who refuse replantation/are not competent, surgeons should seek emergency assistance from the psychiatry team to determine the best management of a self-inflicted amputation. Therapy/Prevention/Etiology/Harm V.

Risk factors for thirty-day morbidity and mortality after spinal trauma.

Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined. Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed. The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87days. Cervical spine injury (p < 0.0001), delay in surgery > 48h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay. Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

Risk factors for damage to the dura mater in thoracic and lumbar spine injury

Objective. To clarify a significance of the risk factors for damage to the dura mater (DM) in fractures of the thoracic and lumbar spine.Material and Methods. The study is based on the analysis of examination data and surgical treatment results of 350 patients with spinal cord injury (SCI). Fractures of the thoracic spine were observed in 124 patients, and those of the lumbar spine in 226. The study included 167 operated patients who underwent posterior decompression at the fracture level using laminectomy and transpedicular fixation of the injured spinal motion segment. There were two groups of patients: study group included 55 patients with DM rupture and control one – 112 patients without damage to the DM.Results. Damage to the DM was found in 32.9 % of patients, the rupture was localized on the posterior surface of the dural sac. In patients with rupture of the dura mater, ASIA type A and B neurological disorders were significantly more common (p = 0.00065). The DM damage occurs significantly more often in patients with type C fracture according to the AOSpine classification, with multilevel spinal injuries and combined SCI (Injury Severity Score more than 27.58 ± 9.46 points). The most significant risk factors for the development of DM ruptures are narrowing of the spinal canal at the fracture level by more than 50 %, a fracture of the vertebral arch, an increase in the relative interpedicular distance of more than 20 %, and diastasis between the fragments of the arches by more than 2.5 mm.Conclusion. The damage to the dura mater is a common complication of vertebral fracture. The prediction of dura mater rupture will allow optimizing surgical approach and improving the treatment outcome.

Localization of Brachial Plexopathies Using a Novel Diagnostic Program.

Background: Assessing the extent and specific location of brachial plexus injuries can be difficult given the variety of mechanisms of injury and anatomic complexity of the plexus. We developed a program to accurately assess the location of a patient's neurologic injury based on electromyographic data. Purpose: We sought to test our hypothesis that the location of traumatic brachial plexopathies could be accurately assessed with a novel program that processed electromyogram (EMG) and mechanism of injury data. Methods: This retrospective diagnostic cohort study was carried out with a novel diagnostic algorithm developed with the Python programming language. The program accepts user input of muscles demonstrating decreased motor unit recruitment, positive sharp waves, or fibrillation potentials. The testing data set was derived from a registry of brachial plexus injuries treated at our center. The primary outcome was the percent concordance of the algorithm's diagnosis with the surgical diagnosis. Results: Ninety-five cases met the inclusion criteria. Median time from injury onset to EMG examination was 4 months; median time from EMG examination to surgery was 1.2 months. The program diagnosis matched the surgical diagnosis in 92 out of 95 (97%) of cases, including cases with multilevel injuries and additional peripheral nerve injuries. Conclusion: This program accurately localized brachial plexopathies in nearly all cases, including those involving polytrauma or complex patterns of injury. This algorithm may be valuable as an aid to complete electrodiagnostic examinations, a diagnostic adjunct when planning treatment of severe plexus palsies, or an educational tool.

Multilevel Spinal Injury: Incidence, Distribution and Neurological Patterns

Introduction: Fractures and dislocation of spine are serious injuries that most commonly occur in young people. Spinal injury at more than one level is not uncommon. Awareness of multilevel injury of the spine and associated neurological patterns is important for the proper initial management of the patient. Methods: This was a prospective observational study carried out in Department of Orthopedics, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal from February 2012 to September 2013. Sixty cases of age group between 18 to 63 years of traumatic spinal injury were enrolled. Patients were examined clinically and radiographically. Results: Out of 60 patients, multilevel spinal injury occurred in 26 (43.3%) patients; 10 (16.67%) had contiguous spinal injury and 16 (26.67%) had non-contiguous spinal injury. There were 5 type A pattern spinal injury. Contiguous spinal injury most commonly occurred at level L1/L2 (n=4, 40%) and most had Frankel grade E neurology (n=6, 60%) followed by Frankel grade D (n=2, 20%). Non-contiguous lesions most commonly occurred at thoracic spine and had Frankel grade E neurology in most cases (n=10, 16.67%) followed by grade B and C (n= 2, 2.33% each). Conclusion: Multiple spinal injury was a common pattern of injury, which occurred in 26 (43.3%) patients out of 60 patients enrolled in our study. Multilevel spinal injury is common. We should be aware about its occurrence. We should evaluate for multilevel spinal injuries, so as not to miss them, specially non-contiguous injuries, in the patients presenting with spinal injury.

Multilevel Spinal Injury: Incidence, Distribution and Neurological Patterns

Introduction Fractures and dislocation of spine are serious injuries that most commonly occur in young people. Spinal injury at more than one level is not uncommon. Awareness of multilevel injury of the spine and associated neurological patterns is important for the proper initial management of the patient.&#x0D; MethodsThis was a prospective observational study carried out in Department of Orthopedics, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal from February 2012 to September 2013. Sixty cases of age group between 18 to 63 years of traumatic spinal injury were enrolled. Patients were examined clinically and radiographically.&#x0D; ResultsOut of 60 patients, multilevel spinal injury occurred in 26 (43.3%) patients; 10 (16.67%) had contiguous spinal injury and 16 (26.67%) had non-contiguous spinal injury. There were 5 type A pattern spinal injury. Contiguous spinal injury most commonly occurred at level L1/L2 (n=4, 40%) and most had Frankel grade E neurology (n=6, 60%) followed by Frankel grade D (n=2, 20%). Non-contiguous lesions most commonly occurred at thoracic spine and had Frankel grade E neurology in most cases (n=10, 16.67%) followed by grade B and C (n= 2, 2.33% each).&#x0D; ConclusionMultiple spinal injury was a common pattern of injury, which occurred in 26 (43.3%) patients out of 60 patients enrolled in our study. Multilevel spinal injury is common. We should be aware about its occurrence. We should evaluate for multilevel spinal injuries, so as not to miss them, especialy non-contiguous injuries, in the patients presenting with spinal injury.

Subacute compartment syndrome in case of gunshot injuries of the extremities

A local hypertensive ischemic syndrome or compartment syndrome (CS) is a serious complication of gunshot injuries of the extremities (GIE), it is usually considered as an acute process. However, we have repeatedly observed patients with subacute course of this pathology.Objective: to study cases of subacute CS (SaCS) with GIE, that are characterized by a latent course and veiled clinical picture of the complications.Methods: there were 15 cases of subacute CS after gunshot injuries for the period 2014–2018. 9 (60 %) were combined injuries of trunk and limbs, 6 (40%) — isolated limb wounds. Lesions of the lower extremities predominated — 10 (66.6 %). In 8 (53.3 %) patients, SaCS developed after shrapnel wounds of the limbs, and in 5 (33.3 %) cases — mine-explosive. Results: in 9 (60 %) cases, SaCS was observed in the bone-fascial sheath of the damaged area of the limb, in 6 (40 %) — in the adjacent segment. In 10 (66.6 %) patients, the course of SaCS was preceded by major vessels injury, in 8 (53.3 %) cases — it was combined with peripheral nerves injuries. In 12 wounded at the stages of evacuation, a tourniquet was used for more than an hour. In 5 cases, the course of SaCS was observed in patients with a combined wound of two or more anatomical sites with the development of a shock or prolonged hypotension. The time from the moment of injury to secondary surgical treatment, when the morphological signs of existed local hypertensive ischemic syndrome in bone-fascial sheath were identified, was from 5 days to 3 weeks.Conclusions: CS in case of GIE can have both acute and subacute flow patterns. SaCS usually develops in the intact segment of the injured limb without pronounced clinical manifestations. Risk factors for the course of SaCS: injuries of the main vessels, tourniquet for more than an hour, multilevel injuries with the development of a shock or prolonged hypotension, incomplete (untimely) fasciotomy at the evacuation stages.

Self-extrication and selective spinal immobilisation in a polytrauma patient with spinal injuries

Methods of extrication and spinal immobilisation following trauma remains controversial. There is a consensus shift towards encouraging patients to self-extricate from vehicles after collisions and reduced use of hard cervical collars. Difficulties in conducting randomised controlled trials in this area means that case reports are important in adding to the existing evidence base. This case of an 81-year-old female polytrauma patient suggests that self-extrication, and not using hard cervical collars is safe practice, even in the context of significant multi-level spinal injuries.

Multi-level Nerve Injury of the Upper Extremity Management and Review of Brachial Plexus Literature: A Case Report

Backround: Brachial plexus injuries are complex cases requiring a thorough understanding of nerve physiology and upper extremity anatomy. Standard approaches and management have been developed but certain situations still arise where these are not feasible options. Objectives: A case of brachial plexus injury is discussed in this report. The patient was a young male who was referred to our center with weakness of the left upper extremity, C5-C7 distribution. Certain components of his injury, such as extensive soft tissue scarring and identification of a long neuroma at the injury site, obliged the surgeons to use unconventional nerve transfers during his surgery. In this paper, we discuss these alternative options in order to support their potential use in complex brachial plexus cases. Other concepts such as single fascicular harvest for nerve transfers and nerve graft augmented nerve transfers are discussed as they were successfully used in this report. Methodology and Results: The patient underwent a total of five surgeries which were a combination of nerve and tendon transfers. Some nerve transfers were augmented with long autologous nerve grafts reaching up to fifteen centimeters in length. Throughout the patients sequence of surgeries, certain nerves, such as the ulnar nerve branch to the flexor carpi ulnaris, successfully served as a donor nerve in more than one occasion. Muscle groups where single nerve fascicles were previously used as a donor nerves also yielded adequate muscle strength and were successfully subsequently used in tendon transfers. Ultimately, the patient was able to achieve good muscle strength, range of motion and outcome scores on his left upper extremity after two years from his final surgery. Conclusion: This report offers multiple alternative options in managing complex brachial plexus cases as well as challenges some concepts in nerve grafting. Alternative donor nerves are offered for transfers, some of which are not previously used in literature. Aside from this, the use of long autologous nerve grafts, single fascicular nerve transfers and repeated use of certain nerves as donor were performed successfully. We hope these procedures and techniques can be added to each hand specialist arsenal for managing complex brachial plexus injuries, specifically when the standard techniques are not feasible.

Factors Affecting Management and Limb Salvage in Upper Limb Vascular Trauma – A Prospective Study of 52 Cases in a Tertiary Care Centre

Introduction: Upper limb vascular trauma although less common than in the lower limbs, is steadily increasing in numbers due to increase in road traffic accidents and work place injuries. It poses as a significant cause of morbidity and has an impact on quality of life compared to lower limb injuries. A prospective study was done to see the factors affecting the type of management and limb salvage in our institute. Methods: Study was done from Dec 2017 till Jan 2019. Total of 52 patients presenting with upper limb vascular injuries were included. Patients were evaluated on the demographics, mode of injury, duration, type of injury, management and surgical procedures. Limb ischemia at the time of presentation was classified according to Rutherford acute limb ischemia classification. Based on the clinical and radiological findings patients were managed surgically or conservatively. Results: Mean age of presentation was 27.3±16.5 years (Range: 2-65) and children < 15years comprised 23% (12). Males outnumbered females with a ratio of 3.7:1. Median time to presentation was 12hours. Blunt injury was the most common type (69%) followed by penetrating (25%) and crush injury (6%). Most common mode of injuries were due to road side accident (RSA) in 53% followed by fall from height (13.5%). Most patients had to Grade-2B ischemia (65%). Two patients presented with Grade-3 ischemia and underwent primary amputation. Right side was more common (52%). There were no bilateral injuries or associated lower limb injuries. Brachial artery injury was the most common artery involved (69%), axillary artery in (13%). Multilevel injury of both brachial and forearm arteries was present in (5.7%). Types of arterial injury included transection (32%), contusion (19%), thrombosis (17%). 67% patients had associated fractures, most common-shaft humerus (48%) and 21% had nerve injuries. 25% patients were managed conservatively with antiplatelets and anticoagulation. Among the patients undergoing surgery, reverse saphenous vein grafting (RSVG) was the most commonly performed procedure (38.5%), followed by thrombectomy (16.5%) and end to end anastomosis (13.5%). One patient underwent secondary amputation. One-month limb salvage rate was 94.2%. There was no significant correlation between time of injury, artery involved and associated bone or nerve injury to the type of management and outcomes. Patients aged < 15 underwent lesser number of fasciotomies and more likely to be managed conservatively (p< 0.001). Conclusion: Upper limb vascular injuries can be dealt with surgery or by conservative management in select group of patients, especially in children < 15years with good limb salvage rates. Disclosure: Nothing to disclose

TRA 2. Factors Affecting Management and Limb Salvage in Upper Limb Vascular Trauma: A Prospective Study of 52 Cases in a Tertiary Care Center

Upper limb vascular trauma, although less common than vascular trauma in the lower limbs, is steadily increasing in numbers because of the increase in road traffic accidents and workplace injuries. It poses a significant cause of morbidity and has an impact on quality of life compared with lower limb injuries. A prospective study was done to see the factors affecting the type of management and limb salvage in our institute. Study was done from December 2017 to January 2019. A total of 52 patients presenting with upper limb vascular injuries were included. Patients were evaluated by demographics, mode of injury, duration, type of injury, management, and surgical procedures. Limb ischemia at the time of presentation was classified according to Rutherford acute limb ischemia classification. Based on the clinical and radiologic findings, patients were managed surgically or conservatively. Mean age at presentation was 27.3 ± 16.5 years (range, 2-65 years), and children <15 years represented 23% (12). Male patients outnumbered female patients with a ratio of 3.7:1. Median time to presentation was 12 hours. Blunt injury was the most common type (69%), followed by penetrating (25%) and crush injury (6%). The most common mode of injury was roadside accident in 53%, followed by fall from height (13.5%). Most patients had grade IIb ischemia (65%). Two patients presented with grade III ischemia and underwent primary amputation. The right side was more common (52%). There were no bilateral injuries or associated lower limb injuries. The brachial artery was most commonly involved (69%); the axillary artery was involved in (13%). Multilevel injury of both brachial and forearm arteries was present in (5.7%). Types of arterial injury included transection (32%), contusion (19%), and thrombosis (17%); 67% of patients had associated fractures, most commonly shaft humerus (48%), and 21% had nerve injuries. Twenty-five percent of patients were managed conservatively with antiplatelets and anticoagulation. Among the patients undergoing surgery, reverse saphenous vein grafting was the most commonly performed procedure (38.5%), followed by thrombectomy (16.5%) and end-to-end anastomosis (13.5%). One patient underwent secondary amputation. The 1-month limb salvage rate was 94.2%. There was no significant correlation of time of injury, artery involved, and associated bone or nerve injury with the type of management and outcomes. Patients aged <15 years underwent fewer fasciotomies and were more likely to be managed conservatively (P < .001). Upper limb vascular injuries can be dealt with by surgery or by conservative management in a select group of patients, especially children <15 years, with good limb salvage rates.

Assessment of Interobserver Variability for CT Scan-Based Evaluation of Posterior Ligament Complex Injury in Thoracolumbar Fractures: An International Multicenter Pilot Study.

Study Design:A multicenter, pilot study, for radiological assessment of thoracolumbar spine fractures was performed with the participation of 7 centers in Africa, Europe, Asia, and South America as a part of the AO Foundation network.Objectives:To determine the interobserver variability for computed tomography (CT) scan–based evaluation of posterior ligament complex (PLC) injury in thoracolumbar fractures.Methods:Forty-two observers including 1 principal investigator at each participating center performed variability assessment. Each center contributed toward a total of 91 patient images with A3 or A4 thoracolumbar burst fractures (T11-L2) with or without suspected PLC injury. Pathological fractures, multilevel injuries, obvious posterior bony element injury and translation/dislocation injuries were excluded. Ten patients were randomly selected and commonly reported CT parameters indicating PLC injury, including superior inferior endplate angle, vertebral body height loss, local kyphotic deformity, interspinous distance and interpedicular distance were assessed for variability. Observer values were compared with an experienced gold rater in spinal trauma. Analysis of variability was performed for all observers, between the principal investigators and also between observers participating in each center.Results:The studied parameters showed considerable variability in measurements among all observers and amongst all participating centers. The variability between the principal investigators was lower, but still substantial. The deviation of observer measurements from the gold rater were also significant for all CT parameters.Conclusions:CT-based radiological parameters previously reported to be suggestive of PLC injury showed considerable variability and magnetic resonance imaging verification of a PLC injury in all doubtful cases is suggested.

Impaired Core Stability as a Risk Factor for the Development of Lower Extremity Overuse Injuries: A Prospective Cohort Study

Background: Core stability has been suggested to influence lower extremity functioning and might contribute to the development of lower extremity overuse injuries. However, prospective studies to investigate this relationship are limited. Purpose: To research the role of different components of core stability as risk factors for the development of lower extremity overuse injuries. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 142 first-year physical education students participated in this study. They were tested in 2015 and were prospectively followed for 1.5 years by means of a multilevel injury registration method. Three participants were excluded owing to physical complaints during testing. As such, 139 participants were included in the statistical analysis. At baseline, dynamic postural control, isometric core and hip muscle strength, core muscle endurance, core neuromuscular control and proprioception, and functional movement were measured for all participants. Competing risk regression analyses were performed to identify significant contributors to the development of lower extremity overuse injuries. Results: During the follow-up period, 34 (24%) of the 139 participants developed a lower extremity overuse injury. Significant predictive effects for an overuse injury were found for an increased side-by-side difference in dynamic postural control (P = .038), decreased isometric hip extension:flexion strength ratio (P = .046), and decreased abdominal core muscle endurance (P = .032). Conclusion: This study identified measures for dynamic postural control, core muscle strength, and core muscle endurance as significant risk factors for the development of overuse injuries after statistical model building. However, core neuromuscular control and proprioception and functional movement might not allow clinicians to identify patients at risk. These accessible, reliable screening tools could be used in clinical practice with regard to screening and injury prevention for overuse injuries. Injury prediction based on this model needs to be done with caution given the low relative predictive accuracy (53%).

Nonfatal Pediatric Injuries Associated With Consumer Products and Sports and Recreational Activities in the United States.

The aim of this study was to investigate the epidemiology of nonfatal consumer product- and sports and recreational activity-related injuries among US children. National Electronic Injury Surveillance System data regarding children younger than 18 years who were treated in US emergency departments (EDs) for nonfatal consumer product- or sports and recreational activity-related injuries were analyzed. From 1990 through 2012, an estimated 121,489,024 (95% confidence interval, 104,226,323-138,751,726) children younger than 18 years were treated in US EDs for nonfatal injuries meeting study criteria, yielding an average of 5,282,131 children annually, or 74.12 injuries per 1000 children. During 1990 to 2005, the overall annual injury rate decreased by 14.0% (P < 0.001), followed by an increase of 7.3% (P = 0.157) during 2005 to 2012. The concussion/closed head injury rate increased by 199.3% (P < 0.001) from 1996 to 2012. Injury rates were highest among children 0 to 4 years old and lowest among children 5 to 9 years old. Sports and recreational activities accounted for 46.5% of all injuries. Falls (40.2%) and "struck-by" (22.6%) were the leading mechanisms of injury, and 62.3% of all injuries were among boys. Injuries often occurred to the head/neck (37.8%) or upper extremities (31.9%), were frequently diagnosed as lacerations (29.0%) or soft tissue injuries (21.0%), and 2.7% were admitted to the hospital. On average, a child was treated in a US ED for a nonfatal consumer product- or sports and recreational activity-related injury every 6 seconds. Although injury rates decreased early in the study period, there was a nonsignificant increasing trend from 2005 to 2012. Multilevel injury prevention efforts are recommended.

From the safety net to the injury prevention web: applying systems thinking to unravel injury prevention challenges and opportunities in Cirque du Soleil

ObjectiveWe undertook this qualitative study within an international circus company—Cirque du Soleil—to explore the narrative of artists and the artistic team in regards to injuries and their prevention and to...

Unstable Multi-Level Ligamentous Injury of the Cervical Spine in an Adolescent

Unstable Multi-Level Ligamentous Injury of the Cervical Spine in an Adolescent

What is the optimal sequence of decompression for multilevel noncontinuous spinal cord compression injuries in rabbits?

BackgroundIn recent years, multilevel spinal cord injuries (SCIs) have gained a substantial amount of attention from clinicians and researchers. Multilevel noncontinuous SCI patients cannot undergo the multiple steps of a one-stage operation because of a poor general condition or a lack of proper surgical approaches. The surgeon subsequently faces the decision of whether to initially relieve the rostral or caudal compression. In this study, we established a spinal cord compression model involving two noncontinuous segments in rabbits to evaluate the effects of differences in decompression order on the functional recovery of the spinal cord.MethodsA Fogarty catheter was inserted into the epidural space through a hole in T6-7 and advanced 3 cm rostrally or caudally. Following successful model establishment, which was demonstrated by an evaluation of evoked potentials, balloons of different volumes (40 μl or 50 μl) were inflated in the experimental groups, whereas no balloons were inflated in the control group. The experimental groups underwent the first decompression in the rostral or caudal area at 1 week post-injury; the second decompression was performed at 2 weeks post-injury. For 6 weeks post-injury, the animals were tested to determine behavioral scores, somatosensory evoked potentials (SEPs) and radiographic imaging changes; histological and apoptosis assay results were subsequently analyzed.ResultsThe behavioral test results and onset latency of the SEPs indicated that there were significant differences between priority rostral decompression (PRD) and priority caudal decompression (PCD) in the 50-μl compression group at 6 weeks post-injury; however, there were no significant differences between the two procedures in the 40-μl group at the same time point. Moreover, there were no significant peak-to-peak amplitude differences between the two procedures in the 50-μl compression group.ConclusionsThe findings of this study suggested that preferential rostral decompression was more beneficial than priority caudal decompression with respect to facilitating spinal cord functional recovery in rabbits with severe paraplegia and may provide clinicians with a reference for the clinical treatment of multiple-segment spinal cord compression injuries.

Long-Term Clinical Outcomes and Factors That Predict Poor Prognosis in Athletes After a Diagnosis of Acute Spondylolysis: A Retrospective Review With Telephone Follow-up.

Study Design Retrospective review with telephone follow-up. Background Acute spondylolytic injuries have a dramatic impact on the young athlete. Excellent short-term clinical outcomes have been observed, but not enough is known about long-term clinical outcomes. Objectives (1) To report long-term clinical outcomes for patients diagnosed with acute spondylolysis, and (2) to assess the prognostic ability of retrospective variables for long-term outcomes. Methods Patients from 2010 through 2013 were retrospectively reviewed to identify patients and to obtain demographic, baseline, and short-term outcomes. Long-term follow-up data were collected by telephone from patients diagnosed with acute spondylolysis to assess recurrence rate of low back pain, perceived outcome, pain, and functional ability. Patients were categorized as having a good or poor long-term outcome based on these measures. Logistic regression analysis was performed to assess the prognostic ability of the retrospective variables for long-term outcomes 3.4 years (range, 1.5-5.6 years) after treatment. Results One hundred twenty-one (71.6%) patients completed the follow-up questionnaire (48 female; mean age at baseline, 14.4 years). At follow-up, 81 (66.9%) patients were able to maintain their same or a higher level of sport. Recurrence of significant symptoms was reported by 55 (45.5%) patients, with 41 (33.9%) requiring medical treatment. The final logistic regression model revealed that female sex, adverse reaction during care, and multilevel injury were significant predictors of poor long-term outcome (R2 = 0.22). Conclusion Although excellent short-term outcomes were noted, 42% of patients reported a poor outcome at long-term follow-up. Female sex, multilevel injury, and experiencing an adverse reaction during care were significant predictors of poor long-term clinical outcome for patients diagnosed with acute spondylolysis. Level of Evidence Prognosis, level 4. Registered January 15, 2015 at www.clinicaltrials.gov (NCT02332200). J Orthop Sports Phys Ther 2016;46(12):1029-1036. Epub 8 Nov 2016. doi:10.2519/jospt.2016.7028.

Assessment of Whole Spine MRI for Multilevel Noncontaguous Spinal Fractures: Incidence, Patterns, and Missed Injuries

Introduction Multi-level non-contiguous spinal injuries are not uncommon and their incidence varies from 1.6 to 77% depending on the type of imaging modality used. Delayed diagnosis and missed spinal injuries in non-contiguous spine fractures have been frequently described which can result in significant pain, deformity and neurological deficit. Mulitlevel injuries patterns have been studied in the past using X-rays and occasionally CT scans. With the growing use of MRI in assessment of spinal trauma scenario the impact of whole spine MRI in evaluation of multilevel injuries have not been assessed in the past. We performed this study to evaluate the impact of using whole spine sagittal MRI in the multilevel spine injuries. Methods Consecutive spinal injury patients treated between 2011 and 2013 were retrospectively evaluated based on clinical and radiographic records. Patient demographics, mode of injury, presence of associated injuries, clinical symptoms and the presence of neurological deficit were studied. Radiographs of the fractured region and whole spine MRI were evaluated for the presence of multi-level injuries We evaluated 484 consecutive patients undergoing whole spine sagittal MRI for multilevel injuries, missed injuries and analyzed the images for specific injury patterns. Results Among 484 patients, ninety five (19.62%) patients had multilevel injuries including 86 (17.76%) with noncontiguous injuries. Five common patterns of non-contiguous spinal injuries between different regions were observed. Pattern I: Cervical and thoracic- 29.1%, Pattern II: Thoracolumbar and lumbosacral - 22.1%, Pattern III: Thoracic and thoracolumbar- 12.8%, Pattern IV: Cervical and thoracolumbar - 9.1% and Pattern V: Lumbosacral and associated injuries- 9.0%. Whole spine MRI scan detected 24 (28.6%) missed secondary injuries of which 5 were unstable. Fall from height was the most common mechanism of injury I in 200 (51.6%), and road traffic accidents contributed to 145 case (37.1%). Neurological deficit was present in 251 patients (64.5%). Complete neurological deficit (ASIA A) was observed in 131 cases(53.3%) while incomplete deficit was present in 120 cases(47.8%). One twenty six patients (32.4%) had associated non-spinal injury including head injury ( n = 19), chest injury ( n = 22), abdomen injury ( n = 4), pelvic injury ( n = 6) and extremity injuries ( n = 75). Conclusion The incidence of multilevel non-contiguous spine injury using whole spine MRI imaging is 17.76%. Five different patterns of multi-level non-contiguous injuries were found with the most common pattern being the cervical and thoracic level injuries. The incidence of missed injuries identified using whole spine MRI was as high as 28.6% and among them the incidence of unstable injuries can be as high as 21%.

La caída casual en Asturias, una causa de lesión medular traumática en ascenso

IntroductionAccidental falls are an increasing cause of traumatic spinal cord injury in Spain. AimsTo assess the incidence and socio-demographic characteristics of traumatic spinal cord injury due to accidental falls in Asturias. Patients and methodsA census was made of patients codified as «traumatic spinal cord injury with or without vertebral fracture» due to falls in Asturias between 1932 and 2013. Socio-demographic, hospital and clinical variables were gathered. ResultsIn total 317 patients were registered, most of them male (68%), with an average age of 56 years±18.8 DT. The estimated incidence in 2012 was 8.4 cases/million/year, with an increasing trend. Accidental falls are currently the leading cause of traumatic spinal cord injury. The distribution in the type of injury was homogeneous (complete in 51.6% and incomplete in 48.4%) and the most common location was cervical (32.2%). Own height falls represented 32% and were associated with a higher mean age and the presence of incomplete injury. Bone injury was present in 76.8%, with multilevel injury in more than half of the patients. ConclusionsAn increasing trend was observed in the proportion of traumatic spinal cord injuries due to accidental falls, related to the aging population. There is a need to create specific preventive and therapeutic strategies.