Traumatic Cervical Spine Fractures Research Articles

Deformity correction in the setting of acute cervical spine trauma in a patient with ankylosing spondylitis: A case report

Introduction: Ankylosing spondylitis (AS) is an autoimmune spondyloarthropathy marked by symptomatic alterations in skeletal anatomy and biomechanics. Ankylosis from the ossification of ligamentous structures and adjacent joints transforms the spine from flexible to rigid and brittle, easily susceptible to fracture. The pathophysiology of the condition is also notable for a progressive debilitating cervical kyphosis known as “chin-on-chest.” Ultimately, the combination of a brittle, rigid, spine can permit trivial trauma to cause catastrophic injury, and in some instances, mortality. We discuss the multi-disciplinary approach, management concerns, and deformity correction in the setting of traumatic cervical spine fracture in a patient with ankylosing spondylitis. Case Report: A 71-year-old man with ankylosing spondylitis presented to Howard University Hospital in a delayed fashion after a ground level fall at home. Neurological examination revealed loss of all motor and sensory function below the C4 level and an absence of rectal tone. Advanced imaging discovered a fracture-dislocation at the C4-5 level producing a severe hyper-lordotic angulation deformity. The profound fracture characteristics and displacement caused spinal cord compression posteriorly and tracheoesophageal stenosis anteriorly. The patient was treated operatively in a staged dual approach fashion correcting his pathologic deformity in consideration of long-term care needs. Postoperatively, upon completion of his final neurosurgical procedure, his sensory exam notable for return of sensation from C5-T1 and he was also able to appreciate and interact with the environment around him as his viewpoint was no longer rigidly caudally oriented. The patient was discharged from the hospital to a long-term care facility in stable condition. Conclusion: Cervical fractures sustained after minor trauma in a patient with ankylosing spondylitis are not uncommon. However, surgical intervention with concomitant deformity correction in the traumatic setting is substantial undertaking with a paucity of literature on such surgical techniques. Surgical deformity correction in the acute trauma setting allowed for optimization of anticipated medical care initiatives and successfully provided newfound visual awareness of his environment, improving upon his ability to interact with the world.

Epidemiological, Clinical and Therapeutic Aspects of Spinal Pathology in Military People in a Country at War

Introduction: Lumbar and sciatic pain are frequent motives of disability in military people in Mali. As spine surgery isn’t recognized enough, our study aims to analyze etiologies, epidemiology, clinical features and surgical standards in order to improve troop abilities. Methodology: Our descriptive and retrospective study has included 31 operated military patients who underwent medical or surgical procedures between 2010 and 2018 in the Military Neurology/Neurosurgery Unit and Mère-Enfant Hospital Neurosurgery department. Results: Among 553 seen in consultation, fifty percent were between 30 and 50 years old. Main motive was sciatic pain (65.5%). Seventy eight percent of our patients were field militaires and sub-officers, and 83.2% were males. All of them have benefited a CT scan or MRI with medical treatment in rheumatology or neurology. Thirty-one patients underwent spine surgery and were included in the study, so 6% (mean age: 43.52 years, 90.3% males). Lumbar spine surgery represented 54.8% of cases with lumbar canal stenosis in 64.5% of cases. It appeared that spondylolisthésis with isthmic fracture was frequent (12.9%), and traumatic cervical spine fractures were dominant in 2012. Instrumented arthrodesis was performed for 41.9% of patients, lumbar discectomy for 32.3% and laminectomies for 22.6%. Degenerative etiology was found in 77.4% of cases and we’ve noticed a good outcome in 93.5% of operated cases. Conclusion: Spinal pathology in military people in Mali is in relation with training, weight carrying and transport conditions on tough terrain. Traumatic traffic injuries are the most common even in war time.

Pilot Study: Age is Not a Factor in Time to Surgery for Traumatic Cervical Spine Fracture Patients.

In a pilot study from an American College of Surgeons (ACS)-verified Level One Trauma Center, we performed a retrospective analysis of patients with cervical spine fractures with or without spinal cord injury (SCI). Long-term mortality was determined from the National Death Index as of December 31, 2013. Examine the influence of age and presence of SCI on time-to-surgery and long-term mortality in patients with cervical spine fractures. Cervical spine fractures with or without SCI disproportionately impact the elderly, who constitute an increasing percentage of the US population. Early surgical intervention is a safe, modifiable factor that enables early mobilization and may reduce complications. Because of increased comorbidities, surgical treatment of elderly patients with cervical spinal fractures is complex, but prolonged time to surgery is increasingly considered as a factor impacting potential recovery after SCI. Retrospective chart review using hospital medical charts and mortality data from the National Death Index. Data from patients with cervical spine fractures treated surgically were analyzed, with nearly equal numbers under and over age 65. There was no statistically significant difference between the 2 age groups with respect to time-to-surgery or long-term mortality. In addition, there was no statistically significant difference between the 2 groups of patients, with or without SCI, with respect to time-to-surgery or long-term mortality. There was no statistically significant differences between patients by age or by SCI status with respect to time-to-surgery or long-term mortality.

Traumatic cervical spine fracture patterns on CT: a retrospective analysis at a level 1 trauma center.

The purpose of our study was to determine common acute traumatic cervical spine fracture patterns on CT cervical spine (CTCS). We retrospectively reviewed 1091 CTCS positive for traumatic fractures performed over a 10-year period at a level 1 trauma center. Fractures were classified by vertebral level, laterality, and anatomic location (anterior/posterior arch, body, odontoid, pedicle, facet, lateral mass, lamina, spinous process, transverse foramina, and transverse processes). C2 was the most commonly fractured vertebra (38% of all studies), followed by C7 (32.4%). 48.7% of studies had upper cervical spine (C1 and/or C2) fractures. 39.7% of positive studies involved > 1 vertebral level. Conditioned on fractures at one cervical level, the probability of fracture was greatest at adjacent levels with a 50% chance of sustaining a C7 fracture with C6 fracture. However, 31.3% (136) of studies with multi-level fractures had non-contiguous fractures. The most common isolated vertebral process fracture was of the transverse process, seen in 89 (8.2%) studies at a single level, 27 (2.5%) studies at multiple levels. Subaxial spine vertebral process fractures outnumbered body fractures with progressive dominance of vertebral process fracture down the spine. C2 was the most commonly fractured vertebral level. Multi-level traumatic cervical spine fractures constituted 40% of our cohort, most commonly at C6/C7 and C1/C2. Although the conditional probability of concurrent fracture in studies with multi-level fractures was greatest in contiguous levels, nearly one-third of multi-level fractures involved non-contiguous fractures.

Vertebral Artery Injury with Coinciding Unstable Cervical Spine Trauma: Mechanisms, Evidence-based Management, and Treatment Options.

Unstable traumatic cervical spine fracture is a commonly encountered neurosurgical issue. Concomitant vertebral artery injuries present a challenge in surgical decision-making regarding the timing and order of surgical intervention with respect to endovascular intervention and internal fixation of the unstable fracture. Currently, there are no studies that have specifically examined stroke rate or outcomes for patients who have vertebral artery injuries and unstable cervical spine fractures with respect to temporal treatment course. The purpose of this paper is to review the current evidence for the standards of diagnosis and management of vertebral artery injuries with coinciding unstable cervical spine injuries and propose an evidence-based algorithm for workup and treatment.

Airtraq® vs. fibreoptic intubation in patients with an unstable cervical spine fracture: A neurophysiological study

BackgroundFibreoptic intubation is described as the preferred technique for the non-urgent airway control in patients with an unstable cervical spine injury. Indirect laryngoscopes offer promising advantages, but their safety and impact on cervical spine movement is still discussed. AimWe compared the incidence of significant neurophysiologic modifications associated with tracheal intubation performed randomly by an Airtraq® videolaryngoscope contrasted with asleep fibreoptic intubation in 40 patients with a traumatic unstable cervical spine fracture immobilized by a moulded cervical collar and scheduled for elective surgery. MethodsSomatosensitive evoked potentials (SSEPs) monitoring was performed at four stages: before airway management (baseline), during facemask ventilation, during intubation and after definitive positioning for surgery. Time, ease of intubation, number of attempts and grade view laryngoscopy were also recorded. ResultsSignificant neurophysiological modifications were detected in one patient in each group during intubation. They were also identified during ventilation in 1/40 patients and 13/40 patients after positioning. Intubation times were significantly shorter when performed by an Airtraq® (median [25th;75th] 45 s [41;54]) than by fiberscope (124 [88;152]), (p < 0.001), and no external manoeuvres were required (vs 18/20 fiberscope group). None of the patients with significative SSEPs modification presented a worsening of their neurological status at discharge. ConclusionTracheal intubation with an Airtraq® appears to be a viable alternative to fibreoptic intubation in patients with a traumatic cervical spine fracture and immobilized by a moulded cervical collar. Time necessary to secure an airway in these patients is significantly shorter with the Airtraq®.

Direct Drop-Down Anterior Approach to Subaxial Cervical Spine

Background: Subaxial cervical spine comprises C3-C7 levels. Southwick and Robinson’s is most commonly used surgical approach for subaxial cervical spine. We are describing a new technique of approaching cervical vertebrae using same planes as in classical approach by Southwick and Robinson. Material and Methods: A total of 35 cases with cervical spine pathologies requiring anterior cervical approach were included in the study. Patients requiring posterior based surgeries, &gt;2-disk level anterior exposure and with history of any previous anterior based cervical spine surgery were excluded from the study. Surgical Technique: The patients were positioned supine on operating table. A 3 cm transverse skin incision is given starting from midline and extending laterally at desired vertebral level. Langenbeck’s retractor of appropriate size is used by surgical assistant to apply gentle constant lateral traction on trachea. The esophagus being invaginated by same pretracheal layer of deep cervical fascia, moves along with trachea. Soft tissue is bluntly dissected with peanut sponge. Steps are repeated till vertebra is reached. Result: Of the 35 cases included in the study, maximum cases (19) were traumatic cervical spine fractures. The average surgical time, intraoperative blood loss in negative suction drains, postoperative hospital stays in this group of cohort was similar to the cohort in which typical traditional approach was used. Discussion: Perceived advantages include—smaller skin incision, less chances to damage carotid sheath and its contents, safe, easy and less time-consuming technique, cosmetically better due to smaller incision size along Langer’s lines.

The impact of body mass index on severity of cervical spine fracture: A retrospective cohort study.

Background:No study has evaluated the relationship between increasing BMI and severity/type of cervical spine injuries.Aims and Objectives:The objective of our study was to study the impact of body mass index (BMI) on severity of cervical spine fracture.Methods:We performed a retrospective cohort study of patients with traumatic cervical spine fractures at a level I trauma center over a 74-year period. CT scans of the cervical spine were blindly graded according to the AO Spine sub-axial cervical spine classification. The association between BMI and severity of cervical spine fracture was studied by multiple-variable logistic regression.Results:A total of 291 patients with an average BMI of 26.1 ± 5.4 kg/m2 were studied. Higher BMI was not associated with more severe injury (OR 1.03, 95%, CI: 0.97–1.08). For rollover motor vehicle accident (MVA), the association was trending towards significance (OR 2.55, 95%, CI: 0.98-6.66, P = 0.06).Conclusions:Patients with higher BMI may be predisposed to more severe cervical spine fracture in rollover MVA, but not non-rollover MVA or falls.

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: the gravity of obesity: 232. The impact of body mass index on severity of cervical spine fracture

BACKGROUND CONTEXT Several studies have analyzed the impact of obesity on severity and specific injury predispositions due to MVA using the Abbreviated Injury Scale (AIS). Although AIS grades individual regions according to severity from minor to maximum, it does not reflect specific description of injury in each region. In the case of cervical spine injury, the type of fracture pattern and spinal cord injury (SCI) cannot be determined from the AIS score. Therefore, the knowledge on impact of obesity on severity of cervical spine injury is limited from prior trauma studies.This information will be useful for providers in the ED to ascertain risk of severe cervical spine injury due to patient's BMI. In addition to risk estimation, fracture pattern, SCI, and patient-specific comorbidities are among important considerations in deciding treatment strategy. PURPOSE The objective of our study was to study the impact of BMI on severity of cervical spine injury after adjusting for injury and patient related variables. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients with traumatic cervical spine fracture presenting to a level I trauma center between January 1, 2010 and December 31, 2014. OUTCOME MEASURES Severity of cervical spine fracture according to AO Spine sub-axial cervical spine fracture classification. METHODS Approval from Institutional Review Board (IRB) was taken before identifying patients for data collection. Review of electronic medical record (EMR) was done to collect patient information. Patients were selected per the following inclusion criteria: (i) traumatic injury that resulted in sub-axial cervical spinal fracture, (ii) patient age 18 to 80 years, (iii) availability of cervical computed tomography (CT) scan, (iv) complete health record of patient clinical and injury characteristics. Patients were excluded if they had isolated atlanto-axial injury or did not have a cervical CT scan. Patients who had suspected pathological fracture were also excluded. CT scans of the cervical spine were assessed by an observer blinded to clinical information.Cervical spine injuries were categorized as severe (S) if they had burst fracture involving both end plates, tension band injuries, and dislocation injuries (Types A4, B0, B1, B2, B3) and/or associated SCI. Injuries with insignificant fractures or single endplate burst morphology (Types A0, A1, A2, A3) and no SCI were categorized as less severe (LS) for our analysis. The association between BMI and severity of cervical spine fracture was studied by multiple-variable logistic regression analysis using a conditional stepwise backward elimination model. The dependent variable was severity of injury with less severe (LS) fracture serving as reference. Independent variable of interest included BMI which was entered as a continuous variable and forced to be in the model at all steps. Other covariates included in the model included age, gender, ethnicity, smoking status, medical comorbidities, mechanism of injury, and other significant organ system injury. All variables were initially entered in the model and backward elimination removal criteria was set at p>.1. RESULTS A total of 751 patients with cervical spine fracture were identified, out of which 291 patients met our inclusion criteria and had adequate records available for analysis. The mean age of included patients was 46.1±19.3 years, and 212 patients (75.8%) were males.Based on morphology of fracture and SCI, 106 (36.4%) were categorized as severe (S) injury. The remaining 185 (63.6%) patients were classified as less severe (LS) injury.%). MVA was the most common injury mechanism (n=177, 60.8%) followed by fall from height (n=85, 29.2%) and random traumatic events (n=29, 10.0%).Our multiple-variable logistic regression model found that increasing BMI was not associated with a likelihood of severe cervical spine injury after adjusting for other clinical and injury parameters (OR 1.03, 95% CI: 0.97–1.08, p=.34). A sub-analysis of MVA cases was done to include side of impact, rollover, protection, and ejection of occupant as covariates in addition to other patient variables. Although trending towards significance, the odds ratio of severe cervical spine injury due to increasing patient BMI was 1.08 (95% CI: 0.99–1.18, p=.06). In this analysis, the presence of rollover was also represented in the final model with OR 2.55 (95% CI: 0.98–6.66, p=.06). CONCLUSIONS In conclusion, our findings indicate that patients with higher BMI may be predisposed to more severe cervical spine fracture and/or SCI after MVA, especially when rollover is present. The same risk may not be present in other common modes of injury such as nonrollover MVA and falls. Further prospective studies with larger sample size, use of clinically relevant outcome parameters (fracture classification, neural deficit), and comprehensive measurement of injury related variables may be helpful to corroborate our findings.

Age and Other Risk Factors Influencing Long-Term Mortality in Patients With Traumatic Cervical Spine Fracture.

Objective:To identify clinical or demographic variables that influence long-term mortality, as well as in-hospital mortality, with a particular focus on the effects of age.Summary and Background Data:Cervical spine fractures with or without spinal cord injury (SCI) disproportionately impact the elderly who constitute an increasing percentage of the US population.Methods:We analyzed data collected for 10 years at a state-designated level I trauma center to identify variables that influenced in-hospital and long-term mortality among elderly patients with traumatic cervical spine fracture with or without SCI. Acute in-hospital mortality was determined from hospital records and long-term mortality within the study period (2003-2013) was determined from the National Death Index. Univariate and multivariate regression analyses were used to identify factors influencing survival.Results:Data from patients (N = 632) with cervical spine fractures were analyzed, the majority (66%) of whom were geriatric (older than age 64). Most patients (62%) had a mild/moderate injury severity score (ISS; median, interquartile range: 6, 5). Patients with SCI had significantly longer lengths of stay (14.1 days), days on a ventilator (3.5 days), and higher ISS (14.9) than patients without SCI (P < .0001 for all). Falls were the leading mechanism of injury for patients older than age 64. Univariate analysis identified that long-term survival decreased significantly for all patients older than age 65 (hazard ratio [HR]: 1.07; P < .0001). Multivariate analysis demonstrated age (HR: 1.08; P < .0001), gender (HR: 1.60; P < .0007), and SCI status (HR: 1.45, P < .02) significantly influenced survival during the study period.Conclusion:This study identified age, gender, and SCI status as significant variables for this study population influencing long-term survival among patients with cervical spine fractures. Our results support the growing notion that cervical spine injuries in geriatric patients with trauma may warrant additional research.

Traumatic Fractures of the Cervical Spine: Analysis of Changes in Incidence, Cause, Concurrent Injuries, and Complications Among 488,262 Patients from 2005 to 2013.

The causes and epidemiology of traumatic cervical spine fracture have not been described with sufficient power or recency. Our goal is to describe demographics, incidence, cause, spinal cord injuries (SCIs), concurrent injuries, treatments, and complications of traumatic cervical spine fractures. A retrospective review was carried out of the Nationwide Inpatient Sample. International Classification of Disease, Ninth Revision E-codes identified trauma cases from 2005 to 2013. Patients with cervical fracture were isolated. Demographics, incidence, cause, fracture levels, concurrent injuries, surgical procedures, and complications were analyzed. t tests elucidated significance for continuous variables and χ2 for categorical variables. Level of significance was P < 0.05. A total of 488,262 patients were isolated (age, 55.96 years; male, 60.0%; white, 77.5%). Incidence (2005, 4.1% vs. 2013, 5.4%), Charlson Comorbidity Index (2005, 0.6150 vs. 2013, 1.1178), and total charges (2005, $71,228.60 vs. 2013, $108,119.29) have increased since 2005, whereas length of stay decreased (2005, 9.22 vs. 2013, 7.86) (all P<0.05). The most common causes were motor vehicle accident (29.3%), falls (23.7%), and pedestrian accidents (15.7%). The most frequent fracture types were closed at C2 (32.0%) and C7 (20.9%). Concurrent injury rates have significantly increased since 2005 (2005, 62.3% vs. 2013, 67.6%). Common concurrent injuries included fractures to the rib/sternum/larynx/trachea (19.6%). Overall fusion rates have increased since 2005 (2005, 15.7% vs. 2013, 18.0%), whereas decompressions and halo insertion rates have decreased (all P < 0.05). SCIs have significantly decreased since 2005, except for upper cervical central cord syndrome. Complication rates have significantly increased since 2005 (2005, 31.6% vs. 2013, 36.2%). Common complications included anemia (7.7%), mortality (6.6%), and acute respiratory distress syndrome (6.6%). Incidence, complications, concurrent injuries, and fusions have increased since 2005. Length of stay, SCIs, decompressions, and halo insertions have decreased. Indicated trends should guide future research in management guidelines.

Cervical spine fractures in osteopetrosis: a case report and review of the literature.

While management of appendicular fractures has been well described in the setting of osteopetrosis, there is limited information on managing fractures of the axial spine. Here we present an osteopetrotic patient with multiple traumatic multiple, comminuted, unstable cervical spinal fractures managed with non-operative stabilization, and provide a review of the pathophysiology, genetic characteristics, and special considerations that must be explored when determining operative versus non-operative management of spinal injury in osteopetrosis. A PubMed query was performed for English articles in the literature published up to June 2016, and used the following search terms alone and in combination: "osteopetrosis", "spine", "fractures", "osteoclasts", and "operative management". Within four months after initial injury, treatment with halo vest allowed for adequate healing. The patient was asymptomatic with cervical spine dynamic radiographs confirming stability at four months. On four-year follow up examination, the patient remained without neck pain, and CT scan demonstrated partially sclerotic fracture lines with appropriate anatomical alignment. In conclusion, external halo stabilization may be an effective option for treatment of multiple unstable acute traumatic cervical spine fractures in patients with osteopetrosis. Given the challenge of surgical stabilization in osteopetrosis, further research is necessary to elucidate the optimal form of treatment in this select patient population.

Anterior cervical distraction and screw elevating-pulling reduction for traumatic cervical spine fractures and dislocations: A retrospective analysis of 86 cases.

Treatment of cervical fracture and dislocation by improving the anterior cervical technique.Anterior cervical approach has been extensively used in treating cervical spine fractures and dislocations. However, when this approach is used in the treatment of locked facet joints, an unsatisfactory intraoperative reduction and prying reduction increases the risk of secondary spinal cord injury. Thus, herein, the cervical anterior approach was improved. With distractor and screw elevation therapy during surgery, the restoration rate is increased, and secondary injury to the spinal cord is avoided.To discuss the feasibility of the surgical method of treating traumatic cervical spine fractures and dislocations and the clinical application.This retrospective study included the duration of patients’ hospitalization from January 2005 to June 2015. The potential risks of surgery (including death and other surgical complications) were explained clearly, and written consents were obtained from all patients before surgery.The study was conducted on 86 patients (54 males and 32 females, average age of 40.1 ± 5.6 years) with traumatic cervical spine fractures and dislocations, who underwent one-stage anterior approach treatment. The effective methods were evaluated by postoperative follow-up.The healing of the surgical incision was monitored in 86 patients. The follow-up duration was 18 to 36 (average 26.4 ± 7.1) months. The patients achieved bones grafted fusion and restored spine stability in 3 to 9 (average 6) months after the surgery. Statistically, significant improvement was observed by Frankel score, visual analog scale score, Japanese Orthopedic Association score, and correction rate of the cervical spine dislocation pre- and postoperative (P < .01).The modified anterior cervical approach is simple with a low risk but a good effect in reduction. In addition, it can reduce the risk of iatrogenic secondary spinal cord injury and maintain optimal cervical spine stability as observed during follow-ups. Therefore, it is suitable for clinical promotion and application.

Cervical vertebral injuries associated with the ossification of the posterior longitudinal ligament: Imaging features.

BackgroundSpinal injuries associated with ossification of the posterior longitudinal ligament (OPLL) have been characterized. However, the imaging features of traumatic cervical spine fractures in patients with OPLL have not been assessed adequately.PurposeTo characterize the patterns of traumatic cervical spine fractures associated with different types of OPLL.Material and MethodsWe retrospectively analyzed the patterns of fractures resulting from cervical spine injury in patients with OPLL of different types and assessed the fracture patterns in patients with ankylosed segments.ResultsTwenty-six patients (23 men, 3 women; median age, 67.0 years; age range, 43–87 years) were included. Fall from a height <3 m was the most common trauma. Contiguous type OPLL was seen in 11 patients (42%), segmental type in 11 (42%), and mixed type in four (15%). Four of the contiguous OPLL and one of the mixed OPLL patients had ankylosed segments. The incidence of cervical fractures was 69% (16/26): seven (64%) in contiguous OPLL, five (46%) in segmental OPLL, and in all four patients with mixed OPLL. Unilateral interfacetal fracture-dislocation was most common (4/16); the others were bilateral interfacetal fracture-dislocation, fractures through the ankylosed segment, transdiscal fractures, isolated facet fractures, and compression fractures. Cervical fractures were exclusively observed in the C4 to C7, except in one case occurred at the C2 level.ConclusionInterfacetal fracture-dislocation in the lower cervical vertebrae constitutes the most common injury resulting from minor trauma.

Cervical fracture patterns associated with vertebral artery injuries

Background: Injury to the vertebral artery commonly occurs in the presence of traumatic cervical spine fractures. Data correlating incidence rates with specific fracture patterns remain unclear. Methods: We reviewed records of adult patients diagnosed with traumatic cervical spine fractures over a 10-year span. Subjects met at least one of the criteria: cervical vertebral subluxations (Pattern 1), fractures involving the transverse foramina (Pattern 2), fractures of C1-C3 (Pattern 3), and comminuted fractures in any segment of the cervical vertebra (Pattern 4). Results: Of the 119 patients included, 30 were diagnosed with vertebral artery injury (25.2%). The highest incidence was demonstrated in patients with the pattern combination of 1 and 2 only (n=3, 66.7%) and, 2 and 4 only (n=3, 66.7%). The next highest incidence was shown in patients with any combination including both pattern 2 and 4 (n=17, 41.1%). Patients with combination 1, 3, and 4 only (n=5, 40.0%), and with any combination including pattern 1 and 2 (n=10, 40.0%) had the third highest incidence. Conclusions: Our analysis demonstrated a high incidence of vertebral artery injury when the transverse foramina was involved and when any combination of three of the four high-risk patterns were involved in traumatic cervical fractures. These findings may be used to suspect vertebral artery injury in high likelihood injuries, reduce costly diagnostic testing, and guide providers to start treatment sooner.

Traumatic cervical spine fractures in the adult

This article reviews fractures of the cervical spine, highlighting the pertinent goals of initial management, the indications for different imaging modalities and the different fracture patterns. Basic principles of management of these different fracture patterns are outlined.

Severe dysphagia requiring gastrostomy following cervical spine fracture fixation.

BackgroundThe incidence of severe dysphagia requiring gastrostomy tube (GT) placement following operative fixation of traumatic cervical spine fractures is unknown. Risk factors for severe dysphagia are not well identified and GT placement is often delayed due to the belief that it will resolve quickly. We hypothesized that patient and clinical factors could be used to predict severe dysphagia requiring GT placement in this population.MethodsA retrospective multicenter review of all adult patients requiring operative fixation of cervical spine fractures was performed. Data on demographics, injury severity score, presence of spinal cord injury, operative approach, presence of severe traumatic brain injury, and the need and timing of tracheostomy and GT were collected. The timing, number and results of formal speech, and language pathology examinations were also recorded.Results243 patients underwent cervical spine fixation for traumatic fractures, of which 72 (30%) required GT placement. Patients requiring gastrostomy were significantly older, 54 versus 45 years (p=0.002), and had higher injury severity scores at 24 versus 18 (p<0.0001). Tracheostomy was strongly associated with severe dysphagia; GT was required in 83% of patients who underwent tracheostomy versus 5% of those who did not require tracheostomy. 50% of patients underwent tracheostomy and GT on the same day after injury, with the remaining patients having an average of 9 days delay between procedures. The need for gastrostomy placement was also higher in patients undergoing combined operative approach versus anterior or posterior approach alone (p=0.02). There were no GT-related complications.ConclusionsSevere dysphagia requiring GT placement occurs commonly (30%) in patients who undergo operative fixation of cervical spine fractures. Gastrostomy placement was delayed in 50%. Tracheostomy was strongly associated with the need for GT placement. Earlier GT placement, especially in patients requiring tracheostomy, would improve patient care and disposition.

Screening via CT angiogram after traumatic cervical spine fractures: narrowing imaging to improve cost effectiveness. Experience of a Level I trauma center.

Screening for vertebral artery injury (VAI) following cervical spine fractures is routinely performed across trauma centers in North America. From 2002 to 2007, the total number of neck CT angiography (CTA) studies performed in the Medicare population after trauma increased from 9796 to 115,021. In the era of cost-effective medical care, the authors aimed to evaluate the utility of CTA screening in detecting VAI and reduce chances of posterior circulation strokes after traumatic cervical spine fractures. A retrospective review of all patients presenting with cervical spine fractures to Northeast Ohio's Level I trauma institution from 2002 to 2012 was performed. There was a total of 1717 cervical spine fractures in patients presenting to Northeast Ohio's Level I trauma institution between 2002 and 2012. CTA screening was performed in 732 patients, and 51 patients (0.7%) were found to have a VAI. Fracture patterns with increased odds of VAI were C-1 and C-2 combined fractures, transverse foramen fractures, and subluxation of adjacent vertebral levels. Ten posterior circulation strokes were identified in this patient population (0.6%) and found in only 4 of 51 cases of VAI (7.8%). High-risk fractures defined by Denver Criteria, VAI, and antiplatelet treatment of VAI were not independent predictors of stroke. Cost-effective screening must be reevaluated in the setting of blunt cervical spine fractures on a case-by-case basis. Further prospective studies must be performed to elucidate the utility of screening for VAI and posterior circulation stroke prevention, if identified.

In Reply to the Letter to the Editor Regarding “Adjacent Level Ligamentous Injury Associated with Traumatic Cervical Spine Fractures: Indications for Imaging and Implications for Treatment”

In Reply to the Letter to the Editor Regarding “Adjacent Level Ligamentous Injury Associated with Traumatic Cervical Spine Fractures: Indications for Imaging and Implications for Treatment”

Letter to the Editor Regarding “Adjacent Level Ligamentous Injury Associated with Traumatic Cervical Spine Fractures: Indications for Imaging and Implications for Treatment”

Letter to the Editor Regarding “Adjacent Level Ligamentous Injury Associated with Traumatic Cervical Spine Fractures: Indications for Imaging and Implications for Treatment”