Traumatic Spinal Injury Patients Research Articles

Intraoperative navigation in surgical management of traumatic spine injury: a propensity score matching analysis.

Traumatic spinal injury (TSI) can lead to severe morbidity and significant health care resource utilization. Intraoperative navigation (ION) systems have been shown to improve outcomes in some populations. However, controversy about the benefit of ION remains. To our knowledge, there is no large database analysis studying the outcomes of ION on TSI patients. Here we hope to compare complications and outcomes in patients with TSI undergoing spinal fusion of 3 or more levels with or without the use of ION. The 2015-2019 National Surgical Quality Improvement Program (NSQIP) database was queried for cases of posterior spinal instrumentation of 3 or more levels. This population was then selected for postoperative diagnosis consistent with TSI. The effect of prolonged operative time was analyzed for all patients. Propensity score matching analysis was performed to create ION case and non-ION control groups. Baseline demographic characteristics, complications, and outcome data were collected and compared between ION and non-ION groups. A total of 1,034 patients were included in the propensity matched analysis. Among comorbidities, only obesity was significantly more likely in the non-ION group. There was no difference in case complexity between the two groups. ION was associated with higher incidence of prolonged operative time but was a negative independent predictor for sepsis. Prolonged operative time was a significant independent predictor for pulmonary embolism and requirement of transfusion in all patients. Discharge to home, readmission, and reoperation rates did not differ between TSI patients with or without ION. Use of ION during posterior spinal fusion of 3 or more levels in TSI patients is not associated with worse outcomes. Prolonged operative time, rather than ION, appears to have a higher influence on the rate of complications in this population. Evaluation of ION in the context of specific populations and pathology is warranted to optimize its use.

Management of Misdiagnosed Bilateral Cervical Facet Dislocation: A Case Report

Background: Despite improvement in technology and decision-making, misdiagnosis or delayed diagnosis of cervical spine injuries in trauma patients can cause severe irreparable neurological damage.
 Case Report: We present here a 56-year-old man, with a history of old bilateral C4-C5 dislocation who, contrarily to classically described unfavorable results of cranial traction in patients with older than 3 weeks cervical injury, underwent optimal reduction under cranial traction for four days and surgical intervention with an anterior surgical approach.
 Conclusion: Relatively high incidence of missed cervical spine injuries in polytrauma patients illustrates that proper clinical examination, use of designed protocols for clearance of cervical trauma, and accurate interpretation of radiological imaging can sometimes be neglected.

Epidemiology of cervical spine injury in Northern India: A retrospective study

Background: The epidemiology of cervical spine injuries in trauma patients of Northern India is largely unknown. Study Design: Retrospective study. Objectives: To find out the epidemiology and demographic factors associated with patients of traumatic cervical spinal injury presented to a level 1 trauma center. Patients and Methods: The study sample includes patients with cervical spine injury admitted to our level one trauma centre from the period of July 2018 to June 2019. Those patients who succumbed to their injuries due to various reasons before imaging or brought dead having suspected cervical spine injury were excluded from the study. Results: During the study period, 83 patients having cervical spine injury were admitted and treated. Out of 83, 75.9% (63) were male and the remaining 24.1% (20) were female. The most common mode of injury was fall from height (66.3%) followed by road traffic accidents (24%). About 64% of the patient population belonged to rural areas. The most affected age group in this study was 20–39 years. The most common associated injury is Extremities fracture (9.6%) followed by head injury (8.4%). C5C6 was the most common level and 69.9% underwent surgery. Pressure sore was presented in 12% of cases. Conclusion: The epidemiology of cervical spine injury in Northern India is different from developed countries. In the present study, the most common cause of cervical spine injury was fall from height followed by motor vehicle accidents. Proper awareness program, educating people, national policymaking, and involvement of NGOs and training primary health care workers will help in reducing the incidence of cervical spine injuries in this region

Preventative interventions, protocols or guidelines for trauma patients at risk of cervical collar-related pressure ulcers: a scoping review.

The objective of this scoping review was to explore the existing literature related to preventative interventions, protocols or guidelines for trauma patients at risk of cervical collar-related pressure ulcers to examine and conceptually map the evidence, and to identify any gaps in the literature. Cervical collars are necessary to stabilize cervical spine injuries in trauma patients; however, pressure ulcers are a major complication of prolonged cervical collar use. The longer a patient wears a cervical collar, the more likely the patient will develop a pressure ulcer that will worsen as wear time increases. This review considered both experimental and quasi-experimental study designs, analytical observational studies, case-control studies, analytical cross-sectional studies, descriptive observational studies, qualitative studies, and text and opinion papers. Trauma patients of all ages who presented to the emergency department or intensive care unit with an extrication or field collar in place were included in this study. Extrication collars included but were not limited to Stifneck, Philadelphia and Miami J. The JBI scoping review methodology was used for this review. The database searches included MEDLINE (PubMed), CINAHL, Embase, Scopus, JBI Database of Systematic Reviews and Implementation Reports, NHS Research Register, National Institute of Health Clinical Trial Databases, Cochrane Database of Sytematic Reviews, MedNar, WorldWideScience, PsycEXTRA, OAIster, OpenGrey, and ProQuest Dissertations and Theses. The data were extracted using a charting table, which was developed to record key information from sources relevant to the review questions. The findings were descriptively presented, with tables and figures to support the data, when appropriate. Only studies in English from 1965 to December 2018 were included. Preventative interventions found in the seven studies included in the review were: removal of the extrication collar, cervical spine clearance, nursing education, routine nursing care, use of products such as air mattresses, and a multidisciplinary approach to care. Additionally, six of the seven studies identified 28 risk factors associated with the development of cervical collar-related pressure ulcers. Two studies reported elimination of cervical collar-related pressure ulcers while three studies reported reduced incidence in cervical collar-related pressure ulcers. Another study reported a reduction in cervical collar wear time from 14 days to 7.7 days. Protocols with a multidisciplinary approach are available in the literature to serve as guidance for proper treatment and care of trauma patients' wearing of cervical collars. Standardized cervical collar protocols should highlight the importance of early identification of trauma patients who may be at risk. Risk factors identified in this review should be assessed and addressed to halt cervical collar-related pressure ulcers from ever developing in trauma patients who are immediately identified as at risk. Preventative interventions identified in the protocols in this scoping review can be used to create a standardized approach to care for patients in cervical collars.

LO027: Cervical spine injury in trauma patients 65 years and older immobilised in the prehospital setting

Introduction: Following a protocol derived from the Canadian C-spine Rule (CCR), patients 65 years and older transported by ambulance after trauma require full spinal immobilisation. Immobilisation complicates the transport and the evaluation; potential side effects have been recognized. The aim of this study was to evaluate the effect of mechanism of trauma and age on the rate of cervical injury in a geriatric population. Methods: We conducted a retrospective observational study on patients 65 years and older transported by ambulance to a level-one trauma center from March 2008 to October 2013. The outcome was the rate of clinically important cervical spine injury (CICSI), defined as any fracture, dislocation or ligamentous injury needing treatment or specialised follow up. The rate was calculated in the geriatric population and in the subgroup of patients with minor trauma, defined as a fall from a standing height, a chair or a bed. We then looked at the rate of CICSI based on age to define a subgroup at lower risk of lesion. Results: We included 1221 patients with a mean age of 80 y.o. (SD = 8), 739 women (61%). CICSI was found in 53 patients (4.3%, 95% CI 3.2-5.4). This is similar to the rate found in patients 65 years and older in the NEXUS population (4.6%) and the CCR population (6.0%). The mechanism of injury was a minor trauma for 716 patients (59%). Of those, 24 patients (3.4%, 95% CI 2.1-4.7) had CICSI. The rate increased after 85 y.o in both the overall population (3.4% vs 6.4%) and the minor trauma subgroup (2.6% vs 4.4%). Conclusion: The subgroup of patients 65-84 y.o. with a minor trauma had the lower rate of cervical spine injury (2.6%). In a lot of prehospital systems, those patients are not systematically immobilised for transport. It will be interesting to review the files of all patients with CICSI to identify any possible case that would have been missed without the age criteria.

429 The Impact of Obesity on Cervical Spine Injuries in Trauma Patients

429 The Impact of Obesity on Cervical Spine Injuries in Trauma Patients

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.

Role of cervical spine radiography in the initial evaluation of stable high-energy blunt trauma patients

BackgroundDetecting cervical spine injuries in trauma patients is essential because undetected injuries in the this area may result in severe neurological disability and probably quadriplegia. Thus, radiography of the cervical spine is considered mandatory in the initial evaluation of trauma patients according to Advanced Trauma Life Support. This approach results in many unnecessary normal radiographs. Therefore, we performed this study to determine the role of routine cervical radiography in the initial evaluation of stable high-energy blunt trauma patients. MethodsThis was a prospective cross-sectional study including all hemodynamically stable high-energy blunt trauma patients with negative cervical physical examinations referred to our trauma center during a 5-month period (May to September 2010). Cervical radiographs, computed tomography (CT) scanning and magnetic resonance imaging were performed and reviewed for abnormalities. ResultsDuring the study period, 1,679 high-energy blunt trauma patients were referred to our center, of which 400 were hemodynamically stable and had negative cervical physical examinations. Cervical radiographs were found to be normal in all patients. ConclusionCross-table cervical spine radiographs can be limited to those high-energy blunt trauma patients who have a positive cervical physical examination or those in whom the physical examination is not revealing. These radiographs also have low value for detecting occult cervical spine fractures, and CT imaging is considered the modality of choice in these cases.

What is the Sensitivity of the Lodox® Statscan in Detecting Cervical Spine Injury Bony Injuries in Trauma Patients

The Statscan is a relatively new imaging modality and is a full body X-ray study with less radiation than traditional radiographs. This is a study to assess the sensitivity of the Lodox® Statscan (Lodox Systems) in detecting cervical spine injuries in trauma patients. Previous studies have given X-ray studies a sensitivity of 45–60%. Our hypothesis is that the Statscan is equally sensitive to the X-ray studies, making them redundant.

Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma

The current standard of practice for clearance of the cervical spine in obtunded patients suffering blunt trauma is to use CT and an adjuvant imaging modality (such as MR imaging). The objective of this study was to determine the comparative effectiveness of multislice helical CT alone to diagnose acute unstable cervical spine injury following blunt trauma. The authors performed a meta-analysis of studies comparing modern CT with adjunctive imaging modalities and required that studies present acute traumatic findings as well as treatment for unstable injuries. Study quality, population characteristics, diagnostic protocols, and outcome data were extracted. Positive disease status included all injuries necessitating surgical or orthotic stabilization identified on imaging and/or clinical follow-up. Seventeen studies encompassing 14,327 patients met the inclusion criteria. Overall, the sensitivity and specificity for modern CT were both > 99.9% (95% CI 0.99-1.00 and 0.99-1.00, respectively). The negative likelihood ratio of an unstable cervical injury after a CT scan negative for acute injury was < 0.001 (95% CI 0.00-0.01), while the negative predictive value of a normal CT scan was 100% (95% CI 0.96-1.00). Global severity of injury, CT slice thickness, and study quality did not significantly affect accuracy estimates. Modern CT alone is sufficient to detect unstable cervical spine injuries in trauma patients. Adjuvant imaging is unnecessary when the CT scan is negative for acute injury. Results of this meta-analysis strongly show that the cervical collar may be removed from obtunded or intubated trauma patients if a modern CT scan is negative for acute injury.

Diagnostic Accuracy of Clinical Examination in Cervical Spine Injuries in Awake and Alert Blunt Trauma Patients

Study DesignObservational, case series.PurposeTo determine the sensitivity and specificity of clinical judgment as compared to the use of X-ray images in detecting cervical spine injuries in trauma patients presenting in the emergency department of Aga Khan University Hospital, Karachi.Overview of LiteratureCross-table cervical spine views are important in patients with signs and symptoms relating to cervical spine, but asymptomatic patients constitute a different subgroup. Accuracy of clinical examination in these patients has not been subjected to scrutiny.MethodsAll patients with blunt trauma who presented to the emergency department and underwent cross-table X-rays as part of their trauma workup were included. The X-rays were read by a radiologist not aware of the history of the patients. We recorded demographic data along with mechanism of injury, associated neck signs or symptoms whether present or not, cervical spine range of motion, associated injuries and X-ray findings. The history and examination were carried out by the on-call neurosurgery team member. The sensitivity and specificity along with negative and positive predictive value of the clinical examination were calculated. Data were analyzed using SPSS ver. 16.0.ResultsOf 50 patients with positive signs and symptoms, 4 (8%) had positive X-rays while only 1 out of 324 (0.3%) with no associated signs and symptoms had positive X-ray findings.ConclusionsThe clinical examination is 80% sensitive and 73.98% specific in detecting true cervical spine injuries as compared to C-spine X-rays in alert and awake patients with blunt trauma.

Increased atlanto-dental interval in a motor vehicle accident victim

Cervical spine injury in trauma patients can lead to devastating neurological injury and therefore it is paramount that cervical spine injury is recognized and appropriately managed as quickly as possible.10 It can be extremely difficult to diagnose cervical spine injury in paediatric patients for several reasons: they may not be able to communicate where they have pain, they may be anxious or crying, they may have distracting injury and the anatomy of the cervical spine varies with age. These factors often result in clinicians taking multiple cervical spine radiographs to exclude pathology. The Red Cross Children's Hospital in South Africa has a large paediatric trauma department which serves the whole Western Cape Province. For the past 2 years, it has been using a StatScan Lodox machine (Lodox Systems, (Pty) Ltd., Sandton, South Africa) to evaluate polytrauma patients.[2] and [3] The benefits of the Lodox machine are three-fold: it is fast, has better resolution of the bronchi, trachea and cervical spine than conventional radiography and it emits a lower dose of ionizing radiation. Over half of the patients who are scanned at this unit are from motor vehicle accidents. We present the case of a 4-year-old child involved in a motor vehicle accident which illustrates the suitability of using the StatScan machine for assessing cervical spine trauma. (A) Reprinted with permission from Elsevier.

Timing of Thoracic Spine Stabilization in Trauma Patients: Impact on Clinical Course and Outcome

Optimal timing of stabilization for thoracic spine injuries in multiply injured patients is still controversial because additional lung injury occurs frequently. Early operation might benefit clinical course and outcome in these patients. We analyzed the German National Trauma Database (n = 8,057) and compared clinical parameters and outcome of patients with severe thoracic spine injuries (Abbreviated Injury Scale >2; n = 298) who underwent spine stabilization within 72 hours posttrauma (group I) or later (group II). In all, 95% of all patients had additional severe thoracic injuries such as lung contusion. In spite of comparable demographic data, patients in group I had a significant shorter intensive care unit (ICU) stay (median [range]: group I, 8 [0-237] days; group II, 16 [2-91] days; p = 0.001), shorter dependence on mechanical ventilation (group I: 2 [0-48] days; group II: 5 [0-91] days; p = 0.02), and shorter hospital stay (group I: 22 [1-255] days; group II: 31 [2-274] days; p = 0.048). Expected mortality calculated by Trauma and Injury Severity Score was significantly reduced in group I (calculated: 16%; documented: 6%; p < 0.05) but not in group II (19% versus 17%; p = NS). Almost 10% of all patients in the German National Trauma Registry had severe spine injuries. Severe thoracic injuries occurred in 95% of these patients with thoracic spine trauma. We provide further evidence that early stabilization of thoracic spine injuries in trauma patients reduces overall hospital and ICU stay and improves outcome. Thus early stabilization of thoracic spine injuries within 3 days after trauma appears to be favorable.

Clinical indications for cervical spine radiographs in the traumatized patient

During a 4 1 2 year period, 4,941 trauma patients were admitted to a hospital, and details of their injuries and treatment were entered in a computerized trauma registry. Using that database, patients with cervical spine injury were studied. Of the 4,941 patients, 1,823 (38 percent) had radiographs of the cervical spine. Ninety-four patients (5 percent) of these patients had injuries of the cervical spine or spinal cord. Sixty five of the 94 patients with cervical spine injury were alert. All had either neck pain or neck tenderness. We do not recommend screening cervical spine radiographs for the alert trauma patient without neck pain; however, we do recommend screening for all patients with decreased levels of consciousness and an injury that could have conceivably injured the cervical spine, for all patients with neurologic deficits compatible with a cervical origin, and for all patients with neck pain or tenderness. Lateral cervical spine radiographs were obtained in all injured patients. They demonstrated cervical spine injury in 70 patients (74 percent) and missed the injury in the remaining 24, which resulted in an unacceptable false-negative rate of 26 percent. We believe that all patients at risk for cervical spine injuries must have complete radiographic examinations of the cervical spine. Computerized axial tomography was the most useful modality to confirm a cervical spine injury in those patients whose lateral cervical spines appeared normal radiographically, especially in patients with associated head injury requiring computerized axial tomography of the brain. Computerized axial tomography diagnosed the injury in 14 of the 24 patients requiring study beyond initial screening. Also presented herein is a radiologic screening algorithm for cervical spine injuries in trauma patients.