Unstable Cervical Spine Injuries Research Articles

The Sensitivity of Limited-Sequence MRI in Identifying Pediatric Cervical Spine Injury: A Western Pediatric Surgery Research Consortium Multicenter Retrospective Cohort Study.

Clinical clearance of a child's cervical spine after trauma is often challenging due to impaired mental status or an unreliable neurologic examination. Magnetic resonance imaging (MRI) is the gold standard for excluding ligamentous injury in children but is constrained by long image acquisition times and frequent need for anesthesia. Limited-sequence MRI (LSMRI) is used in evaluating the evolution of traumatic brain injury and may also be useful for cervical spine clearance while potentially avoiding the need for anesthesia. The purpose of this study was to assess the sensitivity and negative predictive value of LSMRI as compared to gold standard full-sequence MRI as a screening tool to rule out clinically significant ligamentous cervical spine injury. We conducted a ten-center, five-year retrospective cohort study (2017-2021) of all children (0-18y) with a cervical spine MRI after blunt trauma. MRI images were re-reviewed by a study pediatric radiologist at each site to determine if the presence of an injury could be identified on limited sequences alone. Unstable cervical spine injury was determined by study neurosurgeon review at each site. We identified 2,663 children less than 18 years of age who underwent an MRI of the cervical spine with 1,008 injuries detected on full-sequence studies. The sensitivity and negative predictive value of LSMRI were both >99% for detecting any injury and 100% for detecting any unstable injury. Young children (age < 5 years) were more likely to be electively intubated or sedated for cervical spine MRI. LSMRI is reliably detects clinically significant ligamentous injury in children after blunt trauma. To decrease anesthesia use and minimize MRI time, trauma centers should develop LSMRI screening protocols for children without a reliable neurologic exam. 2 (Diagnostic Tests or Criteria).

Emergency Treatment of Cervical Vertebromedullary Trauma: 10 Years of Experience and Outcome Evaluation.

The aim of the study is to identify and validate, through the recording of clinical and radiological data, the different surgical approaches and treatments valid for most subaxial cervical dislocation fractures and whether there is an advantage from using an anterior approach rather than a posterior approach and conversely.. A retrospective study was carried out analyzing the case history of the last 10 years of vertebromedullary traumas treated at the spine surgery unit of the Policlinico Gemelli in Rome. Data on surgical timing, American Spinal Injury Association (ASIA) scores for neurological damage, and subsequent assessments on recovery, survival, and mortality were also examined. A total of 80 patients were treated: 50 by the posterior approach, 24 by the anterior approach, and six by the double approach. Our average follow-up time was 4.2 years. A prevalence of surgery with the posterior approach was noted. We observed the worsening of cervical kyphosis about 15 months after the trauma in two cases treated with the posterior approach alone. A second surgical treatment was performed in these patients. One of these patients underwent an anterior fusion; the other case underwent a posterior revision because the patient had ankylosing spondylitis. Although we found no statistically significant difference in outcomes between the various surgical treatments, in this retrospective study, we analyzed the characteristics and outcomes of cervical spine injuries that required surgical treatment. The aim of surgery in unstable cervical spine injuries should be to reduce and stabilize the damaged segment, maintain lordosis, and decompress when indicated. The optimal choice of surgical approach and treatment, or its superiority in terms of outcomes, remains a debated issue.

Awake fiberoptic intubation in a pediatric patient with cervical spine injuries on a halo-vest: a case report

Awake fiberoptic intubation (AFOI) in pediatric patients remains a continuous challenge for the anesthetists, and is considered more cumbersome a procedure as compared to the adult population. The coexistence of unstable cervical spine injuries, although rare, but complicates the procedure even more. Proper pre-planning, adequate sedation and analgesia and the patient’s conscious cooperation are needed to ensure success. We describe a step-by-step approach to a successful AFOI in a 12-year-old child who had atlantooccipital instability and had a halo-vest on. Titrated dose of sedation and analgesia, obtunding airway reflex and patient’s cooperation is a key to successful AFOI in this patient.&#x0D; Abbreviations: AFIO: Awake fiberoptic intubation; OMF: Oromaxillofacial; BMI: body mass index; TCI: Target-controlled infusion&#x0D; Key words: Airway Management; Airway Obstruction / complications; Anesthesia / methods; Child; Dexmedetomidine, Intravenous infusion; Fiber Optic Technology; Intubation, Intratracheal / methods; Laryngoscopes; Pediatric&#x0D; Citation: Hassan MH. Awake fiberoptic intubation in a pediatric patient with cervical spine injuries on a halo-vest: a case report. Anaesth. pain intensive care 2022;26(4):569-573; DOI: 10.35975/apic.v26i4.1968&#x0D; Received: April 30, 2022; Reviewed: May 01, 2022; Accepted: June 28, 2022

Accuracy of ct evaluation for cervical spine clearance in the ground level fall population – a retrospective cohort study

BackgroundClinically occult cervical spine (CS) injuries are well described in blunt trauma, however delay in identifying these injuries and clearing the CS can result in morbidity. Our study examines the ground level fall (GLF) population to analyze whether computed tomography (CT) alone can rule out unstable injury in this group with lower force mechanism.MethodsThis is a single center, retrospective cohort study. All GLF patients in the institutional trauma registry between 6/1/2012 through 12/31/2019 were included. These comprise all trauma patients evaluated in the emergency department with Injury Severity Score (ISS) > 0, including both activations and consults with both clinical and radiological spine evaluation. Patients who could not be cleared by National Emergency X-ray Utilization Study (NEXUS) criteria underwent CT. Patients with CT or clinical suspicion of cord or ligamentous injury underwent MRI. CT occult injuries were identified by MRI and clinical exam, with MRI identifying all unstable injuries.ResultsSixty-nine (2.0%) of patients had CS injury without acute CT abnormality. Of these, 11 (0.3%) required surgery and were considered unstable. All patients who required surgery had a neurologic deficit. Negative predictive value (NPV) of CT for unstable CS injury was 99.7%. The combination of acute CT findings and neurologic deficit ruled out unstable CS injury with 100% NPV.ConclusionIn the GLF population, CT alone rules out unstable CS injury with high, but not perfect NPV. The combination of absence of acute CT findings and acute neurologic deficits rules out unstable CS injury with 100% NPV.

Anterior Cervical Discectomy and Fusion (ACDF) with Stabilization by cervical locking plate and screw in traumatic sub-axial incomplete cervical spine injury: Early experience

Introduction: Cervical spine injuries represent 2 to 6% of adult blunt trauma, and one third of all spinal injuries. Anterior approach of operative management of cervical spinal injury with incomplete neurological lesion has least analyzed in our settings, the present study has been designed to evaluate the outcome of ACDF and stabilization by cervical plate and screw for managing traumatic cervical spine injury with incomplete neurological deficit.Methods: This study was conducted at NITOR, Dhaka, from July 2016 to June 2018.Twenty available patients meeting the inclusion & exclusion criteria were included. All cases were properly evaluated pre-operatively and underwent ACDF & stabilization with cervical plate and screws. Follow up was done for 5 to 12 months. The final assessment was done by ASIA impairment scale, MRC grading, Bridewell fusion grade, Denis work & pain scale and modified Odom’s criteria.Results: Highest number of patients 10 (50%) were in ASIA grade B, 7(35.0%) patients were in ASIA grade D and 3(15.0%) patients were in ASIA grade C on admission. But in last follow up, highest number of patients were in ASIA grade E (45%). The ASIA grade has improved 1 grade in 55% cases. Bridewell fusion grade showed anterior fusion grade I in 55% of cases, grade II in 45% cases. 60% of cases were in W2 group of Denis work scale after last follow up. Early post-operative complications were dysphagia (20%), respiratory distress (5%) and neck pain (20%). Late post-operative complications were neck pain (10%), donor site pain (5%) and bed sore (5%). According to modified Odom’s criteria, 65% of the cases were found excellent.Conclusion: On the basis of the results in this study, it can be said that anterior cervical decompression, stabilization and fusion by bone graft of the patients who have traumatic unstable cervical spine injury with incomplete neurological lesion will provide effective benefit.

Stabilization does not guarantee neurological recovery but prevents deterioration in the management of AO type-B Sub axial cervical spine injuries: 15 years clinic-radiological outcome from a retrospective cohort analysis

Study Design: Retrospective cohort analysis. Purpose: To evaluate the long-term clinical and radiological outcome of AO type-B Sub axial cervical spine fractures managed with combined anterior and posterior spinal fusion. Overview of Literature: AO Type-B sub axial Cervical fractures involve disruption of the anterior column and posterior tension band osteoligamentous complex. Such injuries demand early surgical management with effective reduction and fusion of the involved vertebra. Though different methods of reduction and surgical approaches have been published in the literature, we preferred global stabilization and fusion and evaluated their long-term outcome. Methods: We retrospectively evaluated 22 patients with post-traumatic unstable sub axial cervical spine injuries which got treated from 2006-2008 with their preoperative clinical details, radiographs, computed tomography, and magnetic resonance imaging of the cervical spine. All patients were managed by immediate reduction, posterior and anterior stabilization, and fusion in a single session of anesthesia. Data of all patients were analyzed with respect to the status of fusion, pre-and post-operative neurological status based on Frenkel staging, along with their complications. Results: The mean age of the included patients was 32.9±12.14 years, with M:F ratio of 21:1. The average length of hospitalization was 20±12.63 days. All patients achieved fusion at a mean period of 4±1.45 months. Among the included 22 patients, only 68.18% (n=15) patients improved from their pre-operative stage whereas the remaining 7 patients did not show any significant improvement in their clinical-grade since injury despite achieving solid fusion at the operated levels at a mean follow-up period of 15.42±1.43 years. No major complications were noted in the included patients. None of the patients showed deterioration in their clinical-grade although 2 patients died in the follow-up period. Conclusions: In AO type-B sub axial cervical injuries, global stabilization and fusion in a single sitting is a viable option in surgical management without major complications. Although the procedure achieves fusion at the intended level, it does not guarantee neurological recovery.

Classification of unilateral cervical locked facet with or without lateral mass-facet fractures and a retrospective observational study of 55 cases

This study describes a morphology-based unilateral cervical facet interlocking classification in an attempt to clarify the injury mechanism, instability, neurological deficits, radiological features, and determine optimum management strategies for these injuries. A total of 55 patients with unilateral cervical locked facet (UCLF) involving C3 to C7 were identified between January 1, 2012 and December 1, 2019. The injuries were classified into three types, and they were further divided into six subtypes using three-dimensional computed tomography. The injury mechanism, clinical features, neurological deficits, and imaging characteristics were analyzed, and the appropriate treatment strategies for UCLF were discussed. UCLFs were divided into the following six subtypes: UCLF without lateral mass-facet fracture (type I) in nine cases, with superior articular process fracture (type II A) in 22, with inferior articular process fracture (type II B) in seven, both superior and inferior articular process fractures (type II C) in four, with lateral mass splitting fracture (type III A) in three, and with lateral mass comminution fractures (type III B) in ten. A total of 22 (40.0%) of the 55 patients presented with radiculopathy, and 23 patients (41.8%) had spinal cord injuries. The subtype analyses showed high rates of radiculopathy in types II A (68.2%) and II C (75.0%), as well as significant spinal cord injury in types I (77.8%) and III (61.5%). Destruction of the facet capsule was observed in all patients, but the injury of disc, ligamentous complex, and vertebra had a significant difference among the types or subtypes. The instability parameters of the axial rotation angle, segmental kyphosis, and sagittal displacement showed significant differences in various types of UCLF. Closed reduction by preoperative and intraoperative general anesthesia traction was achieved in 27 patients (49.1%), and successful rate of closed reduction in type I (22.2%) was significantly lower than that in type II (51.5%) and type III (61.5%). A total of 35 of 55 patients underwent a single anterior fixation and fusion, 10 patients were treated with posterior pedicle and (or) lateral mass fixation, and combined surgery was performed in ten patients. Ten patients (18.2%) with a poor outcome were observed after first surgery. Among them, 3 patients treated with a single anterior surgery had persistent or aggravated radiculopathy and posterior approach surgery with ipsilateral facet resection, foramen enlargement, and pedicle and (or) lateral mass screw fixation was performed immediately, 5 patients treated with a short-segment posterior surgery showed mild late kyphosis deformity, and 2 patients with vertebral malalignment were encountered after anterior single-level fusion during the follow-up. This retrospective study indicated that UCLF is a rotationally unstable cervical spine injury. The classification proposed in this study will contribute to understanding the injury mechanism, radiological characteristics, and neurological deficits in various types of UCLF, which will help the surgeons to evaluate the preoperative closed reduction and guide the selection of surgical approach and fusion segment.

Vertebral artery occlusion associated with blunt traumatic cervical spine injury.

AimVertebral artery injury associated with blunt traumatic cervical spine injury sometimes causes severe cerebellar and brain stem infarction. No treatment guidelines for vertebral artery injury aimed at preventing stroke have been decided. We have conducted endovascular embolization in patients with up to Denver grade IV cerebrovascular injury complicated by unstable cervical spine injury before open reduction and fixation surgery. The purpose of this study was to validate the clinical course of vertebral artery injury and especially endovascular treatment for grade IV patients in our hospital.MethodsParticipants comprised of patients diagnosed as having traumatic cervical spine injury in our hospital between January 2015 and April 2018. Among these patients, we selected those with vertebral artery injury and retrospectively examined the background characteristics of the patients, details of treatment, and complications with or without stroke.ResultsTraumatic cervical spine injury was diagnosed in 89 patients. Among these patients, 15 (16.7%) showed a complicating vertebral artery injury. Mean age was 62.6 years, and almost 50% of the patients were injured in falls. Three types of cervical spine injury caused vertebral artery injury: subluxation, Jefferson fracture, and fracture involving the foramen transversarium. Vertebral artery injury was classified as grade IV in 12 patients, of whom nine required spinal surgery. All patients who needed spinal surgery underwent endovascular therapy before surgery, and none experienced a stroke.ConclusionEndovascular embolization of the vertebral artery occlusion in patients with unstable cervical spine injury before open reduction and fixation surgery can be a treatment option to prevent stroke.

Diagnostic Accuracy and Prognostic Significance of Point-Of-Care Ultrasound (POCUS) for Traumatic Cervical Spine in Emergency care setting: A Comparison of clinical outcomes between POCUS and Computed Tomography on a Cohort of 284 Cases and Review of Literature.

Background:The cervical spine is injured in approximately 3% of major trauma patients, and 10% of patients with serious head injury. Therefore, clearance of the cervical spine in multitrauma patients is a critically important task. This is particularly important, considering that there is a positive correlation between a Glasgow Coma Scale of <14 and cervical spine injury. Radiography is not sensitive enough to rule out cervical spine injury, especially as radiography done in the trauma setting is usually technically unsatisfactory.Objective:The current study aims to assess the diagnostic accuracy and prognostic significance of using bedside point-of-care ultrasound (POCUS) in traumatic cervical spine injuries compared to computed tomography (CT) as the reference standard.Materials and Methods:This comparative study enrolled 284 patients with severe multiple trauma at a tertiary care center between July 2017 and March 2020. The inclusion criteria included an indication of cervical spine CT scan, satisfaction of patients with participation in the study, and the lack of history of injury and severe traumatic events. The exclusion criteria were the history of a previous cervical spinal trauma, spondylosis, scoliosis, spinal tuberculosis, degenerative vertebral changes, and patients who refused to give consent to participate in research or CT scanning. The data were analyzed by SPSS software, and sensitivity, specificity, and positive predictive value (PPV)/negative predictive value (NPV) were determined based on CT findings.Results:The best window for the cervical spine was through the anterior triangle using the linear array probe (6–13 MHz). POCUS had a sensitivity of 78.5%, specificity of 98.4%, PPV of 93.2%, NPV of 92.8%, and accuracy of 93.2% in detecting all types of spinal injuries in comparison with CT scan as the standard modality. POCUS had a sensitivity of 100%, specificity of 92.3%, PPV of 62.3%, NPV of 100%, and accuracy of 91.7% in cases with the movement of injured particles. POCUS had a sensitivity of 32.2%, specificity of 100%, PPV of 100%, NPV of 91.4%, and accuracy of 90.8% in detecting the fracture of transverse process. POCUS had a sensitivity of 36.1%, specificity of 100%, PPV of 100%, NPV of 98.1%, and accuracy of 98.4% in ≤14-year age multitrauma patients. In comparison, the current study achieved a sensitivity of 79.4%, specificity of 95.7%, PPV of 92.1%, NPV of 86.3%, and accuracy of 88.6% in >14-year age multitrauma patients.Conclusion:POCUS for cervical spine is feasible using portable ultrasound machine and by neurosurgeons/radiologists/emergency physicians with basic training. It holds great potential in resource-starved settings and in unstable patients for ruling out unstable cervical spine injuries and injuries associated with the movement of fractured or dislocated particles. POCUS examination of the cervical spine was possible in the emergency setting and even in unstable patients and could be done without moving the neck. Future studies, ideally conducted as randomized control trials, are required to establish training and education standards, and to assess the feasibility and safety of POCUS as an alternative to radiography.

The Utility of Magnetic Resonance Imaging for Detecting Unstable Cervical Spine Injuries in the Neurologically Intact Traumatized Patient Following Negative Computed Tomography Imaging.

Neurologically intact blunt trauma patients with persistent neck pain and negative computed tomography (CT) imaging frequently undergo magnetic resonance imaging (MRI) for evaluation of occult cervical spine injury. There is a paucity of data to support or refute this practice. This study was therefore performed to evaluate the utility of cervical spine MRI in neurologically intact blunt trauma patients with negative CT imaging. A retrospective review was performed of all neurologically intact blunt trauma patients presenting to a level 1 trauma center from 2005 to 2015 with persistent neck pain and negative CT imaging. The proportion of patients with positive MRI findings, subsequent treatment, and time required to obtain MRI results was evaluated. Of 223 patients meeting inclusion criteria, 11 had positive MRI findings; however, no patients were found to have unstable injuries requiring surgical treatment. The process for a complete evaluation of unstable cervical spine injury from the time of obtaining a CT scan was 19 hours and 43 minutes. Eleven patients had positive MRI findings, yet these findings did not alter treatment. In contrast, the time required to obtain MRI results may substantially delay patient care. IV (retrospective case series) CLINICAL RELEVANCE: Our results demonstrate that MRI has limited utility in neurologically intact blunt trauma patients with negative CT imaging.

Comparison of TruView and King Vision video laryngoscopes in subaxial cervical spine injury: A randomized controlled trial.

Background: Airway management with cervical spine immobilization poses a particular challenge for intubation in the absence of neck extension and risks neurological damage in cases of unstable cervical spine injuries. Here, with manual inline stabilization (MILS) in patients with cervical spine injuries, we compared the safety/efficacy of intubation utilizing the TruView versus King Vision video laryngoscopes.Methods: This prospective, single-blind, comparative study was conducted over a 3-year period. The study population included 60 American Society of Anesthesiologists (ASA) Grade I-III patients, aged 18–65 years, who underwent subaxial cervical spine surgery utilizing two intubation techniques; TruView (TV) versus King Vision (KV). For both groups, relative intubation difficulty scores (IDS), total duration of intubation, hemodynamic changes, and other complications (e.g., soft-tissue injury and neurological deterioration) were recorded.Results: With MILS, patients in the KV group had statistically significant lower IDS (0.70 ± 1.02) and significantly shorter duration of intubation as compared to the TV group (1.67 ± 1.27) with MILS (P = 0.0010); notably, the glottic exposure was similar in both groups. The complication rate (e.g., soft-tissue injury) was lower for the KV group, but this was not statistically significant. Interestingly, no patient from either group exhibited increased neurological deterioration attributable to the method of intubation.Conclusion: King Vision has several advantages over TruView for intubating patients who have sustained cervical spine trauma. Nevertheless, both laryngoscopes afford comparable glottic views and safety profiles with similar alterations in hemodynamics.

Not Yet Time to Abandon Cervical Collars in Blunt Trauma

In the evidence-based summary by Serigano et al. (Ref 1.) published in this issue of Academic Emergency Medicine under the Brass Tacks series, the authors critically appraise the evidence for the long-standing practice of prehospital and emergency department cervical spinal motion restriction (SMR) in blunt trauma patients. They highlight the absence of class I data demonstrating a benefit and describe some of the potentially harmful side effects of cervical collars.

Posterior Occipitocervical Fusion for Unstable Upper Cervical Trauma in Old and Elderly Population, Although Decreases Upper Cervical Rotation, Does Not Significantly Increase Neck Disability Index.

Background Despite the research progress in the thoraco-lumbo-pelvic balance, cervical spine balance has only recently gained increasing interest. To our knowledge, there is a lack of research regarding sagittal occipitocervical spine balance restoration following posterior occipitocervical fusion (POCF). Purpose The primary outcome measure is the evaluation of sagittal cervical alignment roentgenographic parameters and the secondary is the functional outcome (NDI), following POCF for upper (C1 & C2) cervical trauma (UCT) in coexistence with upper cervical spine degeneration. Patients and Methods. Twenty old and elderly patients aged 62 ± 12 years with evident upper cervical degeneration, who received POCF for upper C1 & C2 unstable cervical spine injuries, were included. C2-C7 lordosis, C2-C7 SVA, spinocranial angle (SCA), T1-slope, neck tilt (NT), thorax inlet angle (TIA), cervical tilt (CT), cranial tilt (CrT), and C0-C1 angle were measured. The subfusion angle was used to study the behavior of the unfused cervical segments below fusion. The Neck Disability Index (NDI) was used for the functional outcome evaluation. 29 age-matched individuals were used as controls for radiographic analysis and self-reported functional status comparison. Results The roentgenographic data were measured 3 and 39 ± 12 months postoperatively. Twelve patients showed no disability, and eight showed mild disability. Postoperatively, the patients stood with less C2-C7 lordosis, SCA, and CT (P < 0.02) but with higher NT (P < 0.02) in comparison to the controls. The patient's neck disability (NDI) was increasing as TIA increases (P=0.023). Subfusion angle seems to adapt to C2-C7 lordosis (P < 0.0033) and C0-C2 angle (P < 0.003) without any changes till the last evaluation. Conclusions POCF sufficiently restored occipitocervical sagittal balance along with functional outcome similar to controls in adult and elderly individuals with evident upper cervical degeneration. We do not recommend POCF for young active individuals without occipitocervical pathology, but in contrary, we recommend the removal of the spinocranial connection hardware after cervical fusion is completed.

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.

鈍的頸椎損傷に合併する椎骨動脈閉塞症例の検討(Vertebral artery occlusion associated with blunt traumatic cervical spine injury)

要旨【目的】鈍的頸椎損傷に合併する椎骨動脈損傷（以下VAI）は，時に重篤な脳梗塞を生じるが，確立された治療指針はない。我々は不安定型頸椎損傷に合併する椎骨動脈閉塞の症例を血管内治療の適応とし，整復固定術前に塞栓術を行ってきた。当院のVAI症例を検討し，椎骨動脈閉塞症例に対する塞栓術や長期予後について報告する。【対象】2015年1月～2018年4月に入院加療を行った全鈍的頸椎外傷症例を対象とした。頭頸部造影CT検査にてVAIの合併を認めた症例について，患者背景，頸椎損傷の形態，Denver grade，治療内容，脳梗塞合併の有無を後方視的に検討した。【結果】対象の鈍的頸椎外傷患者は89例で，15例（16.7%）にVAIを合併した。VAI患者の平均年齢は62.6歳で，半数が転倒転落を受傷機転とした。VAIの原因となった頸椎損傷は①亜脱臼，②環椎破裂骨折，③横突起骨折の3つであった。Denver grade IVの症例が最も多く12例であり，うち整復固定術を必要とした9例に血管内治療を行い，入院中および退院後のフォローにおいて明らかな脳梗塞を生じた症例は認めなかった。【結語】不安定性頸椎損傷に合併する椎骨動脈閉塞症例に対する整復固定術前の予防的塞栓術は，脳梗塞発症の予防に有効な治療手段となる可能性がある。

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®.

A technique to increase accuracy of cervical pedicle screw insertion for unstable cervical spine injuries −Large-angle insertion from posterolateral approach with lateral view fluoroscopy−

A technique to increase accuracy of cervical pedicle screw insertion for unstable cervical spine injuries −Large-angle insertion from posterolateral approach with lateral view fluoroscopy−

Subaxial Cervical Spine Injuries: Outcomes after Anterior Corpectomy and Instrumentation.

Study Design:This is prospective study.Purpose:The purpose of this study is to assess the functional, neurological, and radiological outcomes of the patients of subaxial cervical spine injuries treated by anterior corpectomy and stabilization with anterior cervical locking plate and cage filled with bone.Overview of the Literature:The principles in the treatment of unstable cervical spine injuries are reduction and stabilization of the injured segment, maintenance of cervical lordosis and decompression where indicated and ranges from nonoperative to combined anterior and posterior surgical fusion. There is, however, debate on the indications for anterior, posterior, or combined surgery.Materials and Methods:The present study of 99 patients includes prospective patients of subaxial cervical spine injuries between February 2014 and February 2016 admitted and operated to Indira Gandhi Medical College, Shimla. Bony fusion, neurological recovery, Neck Disability Index and complication were studied in all patients. The mean follow-up period was 27 months (range 12–42 months).Results:Of the 99 procedures, 77 (77.8%) involved a single vertebral level, 19 (19.2%) involved two levels, and 3 (3%) involved three levels corpectomy. The mean Neck Disability Index was 7.57 ± 5.42. Definitive Bridwell Grade 1 fusion was seen in 64.6% of the cases. No deterioration of neurological symptoms was seen. Dysphagia was the most common complication in 79 (79.8%) patients. One patient had minimal screw back out.Conclusions:Anterior cervical corpectomy and stabilization with cage filled with bone and cervical reflex locking plate are good method for subaxial cervical spine injuries with good fusion rates and probably procedure of choice for posttraumatic multiple disc prolapse with reduced hazards of multiple grafts.

Computed tomography vs. magnetic resonance imaging in unstable cervical spine injuries.

This study aimed to investigate the role of computed tomography (CT) in identifying missed unstable blunt cervical injuries. Patients admitted to the emergency department between June 2014 and June 2018 with a diagnosis of blunt cervical trauma were included in this study. All participants underwent cervical magnetic resonance imaging (MRI) after an initial cervical CT investigation. All imaging results were reviewed, and decisions were taken by the consensus of a team consisting of an emergency medicine specialist, a neuroradiologist, and a neurosurgeon. Other variables included age, sex, the Glasgow Coma Scale, medical comorbidities, multi-trauma, neurological deficits, accompanying intracranial hemorrhage, extremity fractures, and the mechanism of the injury. Data for 195 patients were analyzed. The mean (±standard deviation) age of the participants was 47.34±21.90 years, and 140 (71.8%) were males. Eighteen patients (9.2%) were below age <18. The most frequent mechanism of injury was fall from height (n=100; 51.3%). Using MRI as the gold standard, the sensitivity of CT in diagnosing unstable cervical injury was 77.7% (95% CI [67.1-86.1]), while its specificity was 100.0% (95% CI [59.0-100.0]). Although computed tomography is relatively good in diagnosing unstable cervical injuries, its sensitivity in detecting positive cases is not as successful. Thus, the use of MRI in patients with an unstable injury seems to be warranted.

Dexmedetomidine nebulization as adjuvant to lignocaine during awake flexible fiberoptic intubation

Sir, Awake fiberoptic intubation (AFOI) is recommended for patients with anticipated difficult airway, failed intubation, and unstable cervical spine injury where optimum positioning for laryngoscopy is difficult to achieve. Preparation includes obtundation of airway reflexes, adequate sedation, and anxiolysis along with preservation patent airway and adequate ventilation. Dexmedetomidine produces hypnosis, amnesia, analgesia, anxiolysis, sympatholysis, and antisialogogue effects; all of them are desired during AFOI.[1] Administration of dexmedetomidine through inhalational route could be a new promising noninvasive method. The bioavailability of dexmedetomidine is 65% and 82% through nasal and buccal mucosa, respectively, following nebulization.[2] Here, we reported a series of four cases of patients with difficult airway in which dexmedetomidine was used as adjuvant to lignocaine nebulization before awake fiberoptic bronchoscope-guided nasotracheal intubation. Written consent was taken from all patients. All these patients were scheduled for mandibular excision and reconstruction under general anesthesia. After shifting the patients to operating room, standard ASA monitor was connected and baseline was taken. Injection glycopyrrolate 0.2 mg i.m., intranasal xylometazoline 0.1%, was given 15 min prior to nebulization to each patient. Patients were nebulized with mixture of 4% lignocaine 10 ml and dexmedetomidine 1 μg/kg by using ultrasonic nebulizer for 15 min followed by fiberoptic bronchoscope-guided nasotracheal intubation. All patients received supplemental oxygen (2 l/min) through the working channel of the bronchoscope. Following intubation, general anesthesia was induced. The parameters observed include heart rate, mean arterial pressure, oxygen saturation at 0, 5, 10, 15 (end of nebulization), and 20 min (just after intubation). Other parameters were observed such as cough and gag reflexes [severity graded as no cough, slight ≤2 coughs, moderate (3–5 coughs), severe (>5 coughs)], patient comfort (cooperative, restless/minimal resistance, severe resistance/requirement for immediate general anesthesia), and signs of lignocaine toxicity. Discussion There were bradycardia and hypotension noted during nebulization in case 2 and 3 as shown in Table 1. Tachycardia was noted at 20 min in case 2 and 4. One episode of cough and gag reflex was noted in case 2. No cough, gag, and other adverse effects such as bronchospasm, seizures due to lignocaine toxicity, and oversedation were recorded in rest of cases as shown in Table 1. Patients were comfortable throughout the procedure.Table 1: Shows vitals parameter and cough/gag reflexes during intubationBrummett et al.[3] studied the effect after perineural dexmedetomidine injection and they attributed to the increased duration of analgesia to the local action of dexmedetomidine. The analgesic effect of dexmedetomidine was not reversed by a ∞2-adrenoceptor antagonist (prazosin or idazoxan), hence confirming its local site of action. Hence, we hypothesize that dexmedetomidine nebulization provides surface analgesia to airway mucosa in addition to its systemic effect due to its effects on peripheral nerve endings. We could not measure systemic levels of the drugs due to lack of this facility in our institute. Hence, we limited the maximum dose of lignocaine to 400 mg and dexmedetomidine 1 μg/kg. For validation of our hypothesis, we further require randomized controlled studies. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.