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Kharel P, Zadro JR, Wong G, Rojanabenjawong K, Traeger A, Linklater J, Maher CG. Effectiveness of implementation strategies for increasing clinicians' use of five validated imaging decision rules for musculoskeletal injuries: a systematic review. BMC Emerg Med 2024; 24:84. [PMID: 38760697 PMCID: PMC11100091 DOI: 10.1186/s12873-024-00996-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 04/29/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Strategies to enhance clinicians' adherence to validated imaging decision rules and increase the appropriateness of imaging remain unclear. OBJECTIVE To evaluate the effectiveness of various implementation strategies for increasing clinicians' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule). DESIGN Systematic review. METHODS The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules. RESULTS We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians' long-term knowledge of the Ottawa Ankle Rules. CONCLUSION Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies.
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Affiliation(s)
- Priti Kharel
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050.
| | - Joshua R Zadro
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
| | - Grace Wong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Adrian Traeger
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
| | | | - Christopher G Maher
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
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Steinheber J, Kanz KG, Biberthaler P, Flatz W, Bogner-Flatz V. [Head injuries and their wound treatment]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:391-402. [PMID: 38619616 DOI: 10.1007/s00113-024-01430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/16/2024]
Abstract
Head injuries are frequent occurrences in emergency departments worldwide and are notable for the fact that attention must be paid to the sequelae of intracranial and extracranial trauma. It is crucial to assess potential intracranial injuries and to strive for both medically sound and esthetically pleasing extracranial outcomes. The aim of this continuing education article is to provide a refresher on knowledge of head injuries and the associated nuances for wound care.
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Affiliation(s)
- Jakob Steinheber
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungschirurgie, Sportmedizin, Kreisklinik Ebersberg, Ebersberg, Deutschland
| | - Karl-Georg Kanz
- Zentrale Notaufnahme, Klinikum rechts der Isar der Technischen Universität München und Ärztlicher Bezirksbeauftragter Rettungsdienst Oberbayern West, München, Deutschland
| | - Peter Biberthaler
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
| | - Wilhelm Flatz
- Klinik und Poliklinik für Radiologie, Ludwig-Maximilians-Universität München, München, Deutschland
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Hamel C, Abdeen N, Avard B, Campbell S, Corser N, Ditkofsky N, Berger F, Murray N. Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline. Can Assoc Radiol J 2024; 75:279-286. [PMID: 37679336 DOI: 10.1177/08465371231182972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.
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Affiliation(s)
- Candyce Hamel
- Canadian Association of Radiologists, Ottawa, ON, Canada
| | - Nishard Abdeen
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Barb Avard
- North York General Hospital, Toronto, ON, Canada
| | - Samuel Campbell
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | - Noah Ditkofsky
- St Michael's Hospital, Toronto, ON, Canada
- Michael Garon Hospital , Toronto, ON, Canada
| | - Ferco Berger
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Leeper WR, James N. Trauma Bay Evaluation and Resuscitative Decision-Making. Surg Clin North Am 2024; 104:293-309. [PMID: 38453303 DOI: 10.1016/j.suc.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
The reader of this article will now have the ability to reflect on all aspects of high-quality trauma bay care, from resuscitation to diagnosis and leadership to debriefing. Although there is no replacement for experience, both clinically and in a simulation environment, trauma clinicians are encouraged to make use of this article both as a primer at the beginning of a trauma rotation and a reference text to revisit after difficult cases in the trauma bay. Also, periods of reflection seem appropriate in the busy but, of course, rewarding career in trauma care.
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Affiliation(s)
- William Robert Leeper
- Department of Surgery, Western University, Victoria Campus, London Health Sciences Center, Room E2-215, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada; Trauma Program at London Health Sciences Center, Division of Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Nicholas James
- London Health Sciences Center, Victoria Campus, Room E2-214, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada; Trauma Program at London Health Sciences Center, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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5
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Tavender E, Eapen N, Wang J, Rausa VC, Babl FE, Phillips N. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev 2024; 3:CD011686. [PMID: 38517085 PMCID: PMC10958760 DOI: 10.1002/14651858.cd011686.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.
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Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Nitaa Eapen
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Vanessa C Rausa
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Australia
- Biomechanics and Spine Research Group, Centre for Children's Health Research, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Australia
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Hawkins SC, Williams J, Bennett BL, Islas A, Quinn R. Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update. Wilderness Environ Med 2024; 35:78S-93S. [PMID: 38379496 DOI: 10.1177/10806032241227232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.
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Affiliation(s)
- Seth C Hawkins
- Department of Emergency Medicine, Wake Forest University, Winston-Salem, NC
| | - Jason Williams
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Arthur Islas
- Department of Family and Community Medicine, University of Nevada, Reno School of Medicine, Reno, NV
| | - Robert Quinn
- Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX
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Haddad E, Al Khoury Salem H, Dohin B. Diagnosis and treatment of cervical spine injuries in children. Orthop Traumatol Surg Res 2024; 110:103762. [PMID: 37992867 DOI: 10.1016/j.otsr.2023.103762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/28/2023] [Accepted: 05/11/2023] [Indexed: 11/24/2023]
Abstract
Cervical spine injuries in children are a common reason for emergency room visits, while bone, ligament or spinal cord cervical lesions are relatively rare (1-1.5% of severe trauma in children) and mainly involve the upper cervical spine. The main causes are sports injuries, accidents at home and traffic accidents. Clinical triage is needed to avoid unnecessary radiation exposure from imaging. We propose a protocol to optimize the diagnosis and treatment. In children, conservative treatment using rigid immobilization (cervical collar or halo-vest) is the preferred option in stable and/or minimally displaced injuries. Frequent clinical and radiological monitoring is required to ensure the patient's condition does not deteriorate due to inappropriate or poorly tolerated treatment. In these cases, surgical treatment can be proposed as second-line treatment. Internal fixation is indicated as the first-line treatment if the injury is unstable or a neurological deficit is present. The fixation methods must be adapted to the pediatric population by taking into account the vertebral volume and residual growth potential. Intraoperative CT scans or neuronavigation can make the surgical procedure safer and easier. Clinical, radiographic and CT scan monitoring should continue until the end of growth in a child who underwent surgical treatment to quickly detect any mechanical complications or sagittal imbalance due to poor craniocervical or cervicothoracic alignment. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Elie Haddad
- Service de chirurgie pédiatrique du Pr. SCALABRE, centre hospitalo-universitaire de Saint-Étienne, hôpital Nord, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France.
| | - Hassan Al Khoury Salem
- Service de chirurgie pédiatrique du Pr. SCALABRE, centre hospitalo-universitaire de Saint-Étienne, hôpital Nord, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France.
| | - Bruno Dohin
- Service de chirurgie pédiatrique du Pr. SCALABRE, centre hospitalo-universitaire de Saint-Étienne, hôpital Nord, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France.
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Sumner C, Kietzman A, Kadom N, Frigini A, Makary MS, Martin A, McKnight C, Retrouvey M, Spieler B, Griffith B. Medical Malpractice and Diagnostic Radiology: Challenges and Opportunities. Acad Radiol 2024; 31:233-241. [PMID: 37741730 DOI: 10.1016/j.acra.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 09/25/2023]
Abstract
Medicolegal challenges in radiology are broad and impact both radiologists and patients. Radiologists may be affected directly by malpractice litigation or indirectly due to defensive imaging ordering practices. Patients also could be harmed physically, emotionally, or financially by unnecessary tests or procedures. As technology advances, the incorporation of artificial intelligence into medicine will bring with it new medicolegal challenges and opportunities. This article reviews the current and emerging direct and indirect effects of medical malpractice on radiologists and summarizes evidence-based solutions.
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Affiliation(s)
- Christina Sumner
- Department of Radiology and Imaging Sciences, Emory University (C.S., N.K.), Atlanta, GA
| | | | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University (C.S., N.K.), Atlanta, GA
| | - Alexandre Frigini
- Department of Radiology, Baylor College of Medicine (A.F.), Houston, TX
| | - Mina S Makary
- Department of Radiology, Ohio State University Wexner Medical Center (M.S.M.), Columbus, OH
| | - Ardenne Martin
- Louisiana State University Health Sciences Center (A.M.), New Orleans, LA
| | - Colin McKnight
- Department of Radiology, Vanderbilt University Medical Center (C.M.), Nashville, TN
| | - Michele Retrouvey
- Department of Radiology, Eastern Virginia Medical School/Medical Center Radiologists (M.R.), Norfolk, VA
| | - Bradley Spieler
- Department of Radiology, University Medical Center, Louisiana State University Health Sciences Center (B.S.), New Orleans, LA
| | - Brent Griffith
- Department of Radiology, Henry Ford Health (B.G.), Detroit, MI.
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Muzyka L, Bradford JM, Teixeira PG, DuBose J, Cardenas TCP, Bach M, Ali S, Robert M, Brown CVR. Trends in prehospital cervical collar utilization in trauma patients: Closer, but not there yet. Acad Emerg Med 2024; 31:36-41. [PMID: 37828864 DOI: 10.1111/acem.14822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/28/2023] [Accepted: 10/09/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE This study aims to assess the change in cervical spine (C-spine) immobilization frequency in trauma patients over time. We hypothesize that the frequency of unnecessary C-spine immobilization has decreased. METHODS A retrospective chart review of adult trauma patients transported to our American College of Surgeons-verified Level I trauma center from January 1, 2014, to December 31, 2021, was performed. Emergency medical services documentation was manually reviewed to record prehospital physiology and the application of a prehospital cervical collar (c-collar). C-spine injuries were defined as cervical vertebral fractures and/or spinal cord injuries. Univariate and year-by-year trend analyses were used to assess changes in C-spine injury and immobilization frequency. RESULTS Among 2906 patients meeting inclusion criteria, 12% sustained C-spine injuries, while 88% did not. Patients with C-spine injuries were more likely to experience blunt trauma (95% vs. 68%, p < 0.001), were older (46 years vs. 41 years, p < 0.001), and had higher Injury Severity Scores (31 vs. 18, p < 0.001). They also exhibited lower initial systolic blood pressures (108 mm Hg vs. 119 mm Hg, p < 0.001), lower heart rates (92 beats/min vs. 97 beats/min, p < 0.05), and lower Glasgow Coma Scale scores (9 vs. 11, p < 0.001). In blunt trauma, c-collars were applied to 83% of patients with C-spine injuries and 75% without; for penetrating trauma, c-collars were applied to 50% of patients with C-spine injuries and only 8% without. Among penetrating trauma patients with C-spine injury, all patients either arrived quadriplegic or did not require emergent neurosurgical intervention. The proportion of patients receiving a c-collar decreased in both blunt and penetrating traumas from 2014 to 2021 (blunt-82% in 2014 to 68% in 2021; penetrating-24% in 2014 to 6% in 2021). CONCLUSIONS Unnecessary C-spine stabilization has decreased from 2014 to 2021. However, c-collars are still being applied to patients who do not need them, both in blunt and in penetrating trauma cases, while not being applied to patients who would benefit from them.
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Affiliation(s)
- Logan Muzyka
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - James M Bradford
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Joseph DuBose
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Tatiana C P Cardenas
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Michelle Bach
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Sadia Ali
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Michelle Robert
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Carlos V R Brown
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
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Jao S, Wang Z, Mukhi A, Chaudhary N, Martin J, Yuan V, Laskowski R, Huang E, Vosswinkel J, Singer AJ, Jawa R. Radiographic cervical spine injury patterns in admitted blunt trauma patients with and without prehospital spinal motion restriction. Trauma Surg Acute Care Open 2023; 8:e001092. [PMID: 38020851 PMCID: PMC10668292 DOI: 10.1136/tsaco-2023-001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives Selective prehospital cervical spine motion restriction (C-SMR) following blunt trauma has increasingly been used by emergency medical service (EMS) providers. We determined rates of prehospital C-SMR and concomitant radiographic injury patterns. Methods A retrospective trauma registry and chart review was conducted for all adult blunt trauma patients who were transported by EMS and hospitalized with radiographic cervical spine injuries from 2011 to 2019 at a level 1 trauma center. Results Of 658 admitted blunt trauma patients with confirmed cervical spine injury by imaging, 117 (17.8%) did not receive prehospital C-SMR. Patients without prehospital C-SMR were significantly older (76 vs 54 years), more often had low fall as mechanism of injury (59.8% vs 15.9%) and had lower Injury Severity Score (10 vs 17). Patients without C-SMR (Non-SMR) experienced the full array of cervical spine injury types and locations. While the non-SMR patients most often had dens fractures,C-SMR patients most often had C7 fractures; frequencies of fractures at the remaining vertebral levels were comparable. On MRI, cervical spinal cord (8.5% vs 19.6%) and ligamentous injuries (5.1% vs 12.6%) occurred less often in non-SMR patients. Approximately 8.5% of non-SMR patients and 20% of C-SMR patients required cervical spine surgery. Conclusion Patients without prehospital C-SMR demonstrate a broad array of cervical spine injuries. While the rates of certain cervical injuries are lower in prehospital non-SMR patients, they are not insignificant. Level of evidence Level III.
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Affiliation(s)
- Susan Jao
- Stony Brook University, Stony Brook, New York, USA
| | - Zhe Wang
- Stony Brook University, Stony Brook, New York, USA
| | - Ambika Mukhi
- Stony Brook University, Stony Brook, New York, USA
| | | | | | | | | | - Emily Huang
- Stony Brook University, Stony Brook, New York, USA
| | | | - Adam J Singer
- Emergency Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Randeep Jawa
- Stony Brook University, Stony Brook, New York, USA
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11
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Kharel P, Zadro JR, Chen Z, Himbury MA, Traeger AC, Linklater J, Maher CG. Awareness and use of five imaging decision rules for musculoskeletal injuries: a systematic review. Int J Emerg Med 2023; 16:85. [PMID: 37957570 PMCID: PMC10644430 DOI: 10.1186/s12245-023-00555-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Several validated decision rules are available for clinicians to guide the appropriate use of imaging for patients with musculoskeletal injuries, including the Canadian CT Head Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study (NEXUS) guideline, Ottawa Ankle Rules and Ottawa Knee Rules. However, it is unclear to what extent clinicians are aware of the rules and are using these five rules in practice. OBJECTIVE To determine the proportion of clinicians that are aware of five imaging decision rules and the proportion that use them in practice. DESIGN Systematic review. METHODS This was a systematic review conducted in accordance with the 'Preferred reporting items for systematic reviews and meta-analyses' (PRISMA) statement. We performed searches in MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Scopus databases to identify observational and experimental studies with data on the following outcomes among clinicians related to five validated imaging decision rules: awareness, use, attitudes, knowledge, and barriers and facilitators to implementation. Where possible, we pooled data using medians to summarise these outcomes. RESULTS We included 39 studies. Studies were conducted in 15 countries (e.g. the USA, Canada, the UK, Australasia, New Zealand) and included various clinician types (e.g. emergency physicians, emergency nurses and nurse practitioners). Among the five decision rules, clinicians' awareness was highest for the Canadian C-Spine Rule (84%, n = 3 studies) and lowest for the Ottawa Knee Rules (18%, n = 2). Clinicians' use was highest for NEXUS (median percentage ranging from 7 to 77%, n = 4) followed by Canadian C-Spine Rule (56-71%, n = 7 studies) and lowest for the Ottawa Knee Rules which ranged from 18 to 58% (n = 4). CONCLUSION Our results suggest that awareness of the five imaging decision rules is low. Changing clinicians' attitudes and knowledge towards these decision rules and addressing barriers to their implementation could increase use.
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Affiliation(s)
- Priti Kharel
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia.
| | - Joshua R Zadro
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia
| | - Zhang Chen
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Madii A Himbury
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Adrian C Traeger
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia
| | | | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia
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Luckhurst CM, Wiberg HM, Brown RL, Bruch SW, Chandler NM, Danielson PD, Draus JM, Fallat ME, Gaines BA, Haynes JH, Inaba K, Islam S, Kaminski SS, Kang HS, Madabhushi VV, Murray J, Nance ML, Qureshi FG, Rubsam J, Stylianos S, Bertsimas DJ, Masiakos PT. Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study. JAMA Surg 2023; 158:1126-1132. [PMID: 37703025 PMCID: PMC10500431 DOI: 10.1001/jamasurg.2023.4213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/16/2023] [Indexed: 09/14/2023]
Abstract
Importance There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure Blunt trauma. Main Outcomes and Measures Primary outcome was CSI. The primary and secondary objectives were predetermined. Results The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.
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Affiliation(s)
- Casey M. Luckhurst
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston
| | | | - Rebeccah L. Brown
- Division of Pediatric Surgery at Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Steven W. Bruch
- Division of Pediatric Surgery at University of Michigan Medical Center, Ann Arbor
| | - Nicole M. Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Paul D. Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - John M. Draus
- Division of Pediatric Surgery at Kentucky Children’s Hospital, Lexington
| | - Mary E. Fallat
- Division of Pediatric Surgery at Norton Children’s Hospital, Louisville, Kentucky
| | - Barbara A. Gaines
- Division of Pediatric Surgery at University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeffrey H. Haynes
- Department of Pediatric Surgery, Children’s Hospital of Richmond at Virginia Commonwealth University Health, Richmond
| | - Kenji Inaba
- Division of Trauma, Emergency Surgery, and Surgical Critical Care at University of Southern California Medical Center, Los Angeles
| | - Saleem Islam
- Division of Pediatric Surgery at University of Florida Health, Gainesville
| | - Stephen S. Kaminski
- Department of Surgery at Santa Barbara Cottage Hospital, Santa Barbara, California
| | - Hae Sung Kang
- Department of Surgery, Virginia Commonwealth University Health, Richmond
| | | | - Jason Murray
- Department of Surgery, University of Texas Health Tyler, Tyler
| | - Michael L. Nance
- Division of Pediatric Surgery at Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Faisal G. Qureshi
- Division of Pediatric Surgery at Children’s Medical Center Dallas, Dallas, Texas
| | - Jeanne Rubsam
- Division of Pediatric Surgery at Morgan Stanley Children’s Hospital of New York-Presbyterian, New York
| | - Steven Stylianos
- Division of Pediatric Surgery at Morgan Stanley Children’s Hospital of New York-Presbyterian, New York
| | | | - Peter T. Masiakos
- Division of Pediatric Surgery, Massachusetts General Hospital, Boston
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13
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Heuer A, Koepke LG, Viezens L, Schroeder M. [Perioperative management after traumatic paraplegia : Avoiding complications]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:749-755. [PMID: 37306757 DOI: 10.1007/s00113-023-01342-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/13/2023]
Abstract
This article describes the current status of modern treatment options for traumatic spinal cord injuries with a particular focus on the perioperative phase. Along with a recognition of age-related specific features that can impact successful treatment of spinal injuries, prompt interdisciplinary treatment while adhering to the "time is spine" principle is of high importance. By considering this approach and using modern diagnostic and surgical techniques, successful surgical treatment can be achieved while taking into account individual characteristics, such as reduced bone quality, accompanying injuries as well as oncological and inflammatory rheumatic comorbidities. The preventive and treatment strategies for frequently occurring complications in the management of traumatic spinal cord injuries are presented. By considering case-specific factors, utilizing modern surgical techniques, avoiding or promptly treating typical complications and initiating interdisciplinary treatment, crucial groundwork for a successful long-term treatment of this highly debilitating and life-altering injury can be established in the perioperative phase.
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Affiliation(s)
- Annika Heuer
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Sektion Wirbelsäulenchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Leon-Gordian Koepke
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Sektion Wirbelsäulenchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Lennart Viezens
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Sektion Wirbelsäulenchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Malte Schroeder
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Sektion Wirbelsäulenchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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14
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Rodriguez NM, Mower WR, Raja AS, Gupta M, Montoy JC, Parry B, Chan V, Wong AHK, Wilcox J, Quiñones A, Rodriguez RM. Accuracy of physician gestalt in prediction of significant abdominal and pelvic injury in adult blunt trauma patients. Acad Emerg Med 2023; 30:1039-1046. [PMID: 37363986 DOI: 10.1111/acem.14768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/24/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Focusing on potential missed injury rates and sensitivity of low-risk of injury predictions, we sought to evaluate the accuracy of physician gestalt in predicting clinically significant injury (CSI) in the abdomen and pelvis among blunt trauma patients presenting to the emergency department (ED). METHODS We collected gestalt data on physicians caring for adult blunt trauma patients who received abdominal/pelvic computed tomography (CT) at three Level I and one Level II trauma centers. The primary outcome of CSI was defined as injury on abdominal/pelvic CT requiring hospitalization or intervention. Physicians evaluating trauma patients estimated the likelihood of CSI prior to abdominal/pelvic CT review (response choices: <2%, 2%-10%, 11%-20%, 21%-40%, >40%). We evaluated potential missed injury rates (prevalence of CSI) and sensitivity for prediction categories, as well as calibration and area under the receiver operating characteristic (AUROC) curve for overall physician gestalt. RESULTS Of 2030 patients, 402 (20%) had an injury on abdominal/pelvic CT and 270 (13%) had CSI. The <2% risk of CSI gestalt cutoff had a potential missed injury rate of 5.6% and a sensitivity of 95.2% (95% confidence interval [CI] 91.7%-97.3%). The 0%-10% cutoff of CSI gestalt had a potential missed injury rate of 6.3% (95% CI, 5.0%-7.9%) and a sensitivity of 75.2% (95% CI 69.5%-80.1%). With an overall AUROC of 0.699 (95% CI 0.679-0.719), physician gestalt was moderately accurate and calibrated for the midranges of predicted risk but poorly calibrated at the extremes. CONCLUSIONS Physician gestalt for the prediction of adult abdominal and pelvic CSI is moderately accurate and calibrated. However, the potential missed CSI rate and low sensitivity of the low perceived risk of injury cutoffs indicate that gestalt by itself is insufficient to direct selective abdominal/pelvic CT use in adult blunt trauma patient evaluation.
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Affiliation(s)
| | | | - Ali S Raja
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Malkeet Gupta
- University of California, Los Angeles, California, USA
- Antelope Valley Medical Center, Lancaster, California, USA
| | | | - Blair Parry
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Virginia Chan
- University of California, San Francisco, California, USA
| | | | - James Wilcox
- Antelope Valley Medical Center, Lancaster, California, USA
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15
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Peterson A, Behrens J, Salari P, Place H. Isolated thoracic and lumbar transverse process fractures: Do they need spine surgeon evaluation? a high volume level I trauma center experience with cost analysis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 15:100242. [PMID: 37560400 PMCID: PMC10407537 DOI: 10.1016/j.xnsj.2023.100242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Transverse process fractures (TPF) of the thoracic and lumbar spine have become increasingly identified due to CT imaging. Spine service consultation is common for further evaluation and management. There are several studies that demonstrate no difference in clinical outcome with or without spine service intervention. However, no study to our knowledge provides an additional cost analysis. We hypothesize that isolated thoracolumbar TPF are stable injuries. Furthermore, spine service consultation and evaluation results in increased health care costs. METHODS Patients were identified using trauma registry data at Saint Louis University (SLU) from January 2012 to August 2018. Chart and imaging review was performed to determine if additional spine fractures were identified by the spine team which were not included in the initial radiology report. TPF associated with other spinal injuries were defined as one or more thoracic and/or lumbar TPF in addition to any other acute fracture or dislocation in the cervical, thoracic, or lumbar spine. A separate cost analysis with institution-specific charges was also performed. RESULTS Six hundred eighty-two patients with TPF from January 2012 to August 2018 were identified. Two hundred twenty-eight patients met the criteria to be included in this study. Additional spinal pathology that was not included in the initial radiology report was identified in 5 (2.19%) patients, none of which required surgical intervention. Cost analysis demonstrated additional costs associated with spine service intervention totaled $1,725,360.28. Average cost per patient in our cohort summed to $2,529.85. CONCLUSIONS These data support that isolated TPF of the thoracic and lumbar spine are stable injuries that likely do not require spine service intervention and in fact may represent unnecessary financial burden. Foregoing unnecessary consultation can alleviate time constraints within spine service practices and reduce health care costs by eliminating costly extraneous interventions from the patient's care.
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Affiliation(s)
- Asa Peterson
- Department of Orthopedic Surgery, Center for Specialized Medicine, St. Louis University Hospital, 1225 S Grand Blvd, St. Louis, MO 63104, United States
| | - Jonathan Behrens
- Department of Orthopedic Surgery, Center for Specialized Medicine, St. Louis University Hospital, 1225 S Grand Blvd, St. Louis, MO 63104, United States
| | | | - Howard Place
- Department of Orthopedic Surgery, Center for Specialized Medicine, St. Louis University Hospital, 1225 S Grand Blvd, St. Louis, MO 63104, United States
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16
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Gregory ME, Truelove A, Ahmad F, Corwin D, Tzimenatos L, Oglesbee SJ, Herman MJ, Leonard JC. Decision-making for pediatric cervical spine imaging after blunt trauma: Investigating team dynamics in the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e13024. [PMID: 37600900 PMCID: PMC10432897 DOI: 10.1002/emp2.13024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/11/2023] [Accepted: 07/26/2023] [Indexed: 08/22/2023] Open
Abstract
Objective Cervical spine imaging decision-making for pediatric traumas is complex and multidisciplinary. Implementing a risk assessment tool has the potential to reduce variation in these decisions and unnecessary radiation exposure for pediatric patients. We sought to determine how emergency department-trauma team dynamics may affect implementation of such a tool. Methods We interviewed (pediatric and general emergency physicians, trauma surgeons, neurosurgeons, orthopedic surgeons and ED nurses at 21 hospitals to ascertain how team dynamics affect the pediatric cervical spine imaging decision-making process. Data were coded following a framework-driven deductive coding process and thematic analysis was used. Results Forty-eight physicians, advanced practice providers, and nurses from 21 hospitals (inclusive of three US regions, trauma levels I-III, and serving towns/cities of various population sizes) were interviewed. Overall, emergency physicians and trauma surgeons indicate being generally responsible for pediatric cervical spine imaging decisions. Conflict often occurs between these specialties due to differential weighting of concerns for missing an injury versus avoiding radiation exposure. Participants described a lack of trust and unclear roles regarding ownership for the final imaging decision. Nurses commonly described low psychological safety that prohibits them from participating in the decision-making process. Conclusions Implementation of a standardized risk assessment tool for cervical spine trauma imaging decisions must consider perspectives of both emergency medicine and trauma. Policies to define appropriate use of standardized tools within this team environment should be developed.
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Affiliation(s)
- Megan E. Gregory
- Department of Health Outcomes and Biomedical InformaticsUniversity of FloridaGainesvilleFloridaUSA
| | - Annie Truelove
- Abigail Wexner Research Institute at Nationwide Children's HospitalColumbusOhioUSA
| | - Fahd Ahmad
- Division of Emergency MedicineDepartment of PediatricsWashington University in St. Louis School of MedicineSt. LouisUSA
| | - Daniel Corwin
- Division of Emergency MedicineDepartment of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Leah Tzimenatos
- Department of Emergency MedicineUniversity of CaliforniaDavis School of MedicineSacramentoCaliforniaUSA
| | - Scott J. Oglesbee
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
| | - Martin J. Herman
- St. Christopher's Hospital for ChildrenPhiladelphiaPennsylvaniaUSA
| | - Julie C. Leonard
- Abigail Wexner Research Institute at Nationwide Children's HospitalColumbusOhioUSA
- Division of Emergency MedicineDepartment of PediatricsThe Ohio State University College of Medicine, and Nationwide Children's HospitalColumbusOhioUSA
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Montoto-Meijide R, Meijide-Faílde R, Díaz-Prado SM, Montoto-Marqués A. Mesenchymal Stem Cell Therapy in Traumatic Spinal Cord Injury: A Systematic Review. Int J Mol Sci 2023; 24:11719. [PMID: 37511478 PMCID: PMC10380897 DOI: 10.3390/ijms241411719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Recovery from a traumatic spinal cord injury (TSCI) is challenging due to the limited regenerative capacity of the central nervous system to restore cells, myelin, and neural connections. Cell therapy, particularly with mesenchymal stem cells (MSCs), holds significant promise for TSCI treatment. This systematic review aims to analyze the efficacy, safety, and therapeutic potential of MSC-based cell therapies in TSCI. A comprehensive search of PUBMED and COCHRANE databases until February 2023 was conducted, combining terms such as "spinal cord injury," "stem cells," "stem cell therapy," "mesenchymal stem cells," and "traumatic spinal cord injury". Among the 53 studies initially identified, 22 (21 clinical trials and 1 case series) were included. Findings from these studies consistently demonstrate improvements in AIS (ASIA Impairment Scale) grades, sensory scores, and, to a lesser extent, motor scores. Meta-analyses further support these positive outcomes. MSC-based therapies have shown short- and medium-term safety, as indicated by the absence of significant adverse events within the studied timeframe. However, caution is required when drawing generalized recommendations due to the limited scientific evidence available. Further research is needed to elucidate the long-term safety and clinical implications of these advancements. Although significant progress has been made, particularly with MSC-based therapies, additional studies exploring other potential future therapies such as gene therapies, neurostimulation techniques, and tissue engineering approaches are essential for a comprehensive understanding of the evolving TSCI treatment landscape.
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Affiliation(s)
- Rodrigo Montoto-Meijide
- Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain
| | - Rosa Meijide-Faílde
- Grupo de Investigación en Terapia Celular y Medicina Regenerativa, Instituto de Investigación Biomédica de A Coruña (INIBIC), Centro Interdisciplinar de Química y Biología (CICA), Universidade da Coruña, 15071 A Coruña, Spain
- Departamento de Fisioterapia, Medicina y Ciencias Biomédicas, Universidade da Coruña, 15071 A Coruña, Spain
| | - Silvia María Díaz-Prado
- Grupo de Investigación en Terapia Celular y Medicina Regenerativa, Instituto de Investigación Biomédica de A Coruña (INIBIC), Centro Interdisciplinar de Química y Biología (CICA), Universidade da Coruña, 15071 A Coruña, Spain
- Departamento de Fisioterapia, Medicina y Ciencias Biomédicas, Universidade da Coruña, 15071 A Coruña, Spain
| | - Antonio Montoto-Marqués
- Departamento de Fisioterapia, Medicina y Ciencias Biomédicas, Universidade da Coruña, 15071 A Coruña, Spain
- Unidad de Lesionados Medulares, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña, 15006 A Coruña, Spain
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Shaffer SM, Naze GS. Evaluation and management of temporomandibular disorders. Part 2: an orthopaedic physical therapy update on examination and clinical reasoning. J Man Manip Ther 2023; 31:143-152. [PMID: 36171740 PMCID: PMC10288906 DOI: 10.1080/10669817.2022.2124617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Temporomandibular (TM) disorders afflict many people globally and, despite the presence of existing peer-reviewed material that assists conservative orthopedic providers, recent advances in knowledge indicate that updated resources are required for students, clinicians, and educators. This two-part series builds off previously published material to present newer supplementary information that can be useful during the evaluation and management processes. Content in Part 1 of this series includes a discussion about the factors that have been shown to contribute to TM disorders, an updated perspective of relevant pain science, a discussion of self-report outcome measures, and various different topics related to the examination of patients with TM disorders. Part 2 addresses information related to the temporomandibular joint disc, joint hypermobility, oral splints, and clinical reasoning. In combination with other available publications, this two-part series provides clinicians an opportunity to improve their delivery of effective and efficient clinical services for people diagnosed with TM disorders.
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Affiliation(s)
- Stephen M. Shaffer
- Department of Rehabilitation Sciences, College of Education, Nursing, and Health Professions, University of Hartford, West Hartford, CT, USA
| | - Garrett S. Naze
- Department of Physical Therapy, Congdon School of Health Sciences, High Point University, High Point, NC, USA
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19
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Leech JB, Owen WE, Young JL, Rhon DI. Incomplete reporting of manual therapy interventions and a lack of clinician and setting diversity in clinical trials for neck pain limits replication and real-world translation. A scoping review. J Man Manip Ther 2023; 31:153-161. [PMID: 36047903 PMCID: PMC10288932 DOI: 10.1080/10669817.2022.2113295] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Neck pain is a leading cause of disability, and manual therapy (MT) is a common intervention used across disciplines and settings to treat it. While there is consistent support for MT in managing neck pain, questions remain about the feasibility of incorporating MT from research into clinical practice. The purpose of this scoping review was to assess the adequacy of MT intervention descriptions and the variability in clinician and setting for MT delivery in trials for neck pain. METHODS Medline (via PubMed), CINAHL, PEDRo, and the Cochrane Central Registry for Controlled Trials were searched for clinical trials published from January 2010 to November 2021. A 11-item tool modified from the Consensus on Exercise Reporting Template was used to assess appropriateness of intervention reporting. Clinicians, subclassifications of neck pain, and clinical settings were also extracted. RESULTS 113 trials were included. A low percentage of studies provided the recommended level of detail in the description of how MT was delivered (4.4%), while 39.0% included no description at all. Just over half of trials included clinician's qualifications (58.4%), dose of MT (59.3%), and occurrence of adverse events (55.8%). The proportion of trials with clinicians delivering MT were physical therapists (77.9%), chiropractors (10.6%), and osteopaths (2.7%). DISCUSSION/CONCLUSION These results reveal incomplete reporting of essential treatment parameters, and a lack of clinician diversity. To foster reproducibility, researchers should report detailed descriptions of MT interventions. Future research should incorporate a variety of MT practitioners to improve generalizability.
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Affiliation(s)
- Joseph B. Leech
- Doctor of Science in Physical Therapy, Bellin College, Green Bay, WI, USA
- Doctor of Physical Therapy Program, College of Rehabilitative Sciences, the University of St. Augustine for Health Sciences, Austin, TX, USA
| | - William E. Owen
- Doctor of Science in Physical Therapy, Bellin College, Green Bay, WI, USA
| | - Jodi L. Young
- Doctor of Science in Physical Therapy, Bellin College, Green Bay, WI, USA
| | - Daniel I. Rhon
- Doctor of Science in Physical Therapy, Bellin College, Green Bay, WI, USA
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
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20
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Shaffer SM, Naze GS. Evaluation and management of temporomandibular disorders. Part 1: an orthopedic physical therapy update on examination and clinical reasoning. J Man Manip Ther 2023; 31:133-142. [PMID: 36245265 PMCID: PMC10288910 DOI: 10.1080/10669817.2022.2123171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Temporomandibular (TM) disorders afflict many people globally and, despite the presence of existing peer-reviewed material that assists conservative orthopedic providers, recent advances in knowledge indicate that updated resources are required for students, clinicians, and educators. This two-part series builds off previously published material to present newer supplementary information that can be useful during the evaluation and management processes. Content in Part 1 of this series includes a discussion about the factors that have been shown to contribute to TM disorders, an updated perspective of relevant pain science, a discussion of self-report outcome measures, and various different topics related to the examination of patients with TM disorders. Part 2 addresses information related to the temporomandibular joint disc, joint hypermobility, oral splints, and clinical reasoning. In combination with other available publications, this two-part series provides clinicians an opportunity to improve their delivery of effective and efficient clinical services for people diagnosed with TM disorders.
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Affiliation(s)
- Stephen M. Shaffer
- College of Education, Nursing, and Health Professions, Department of Rehabilitation Sciences, University of Hartford, West Hartford, CT, USA
| | - Garrett S. Naze
- Congdon School of Health Sciences, Department of Physical Therapy, High Point University, High Point, NC, USA
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21
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Manville C, Edwards S, Bloom B, Moore N. Cervical immobilisation in elderly patients with a suspected cervical spine fracture: a retrospective study. Eur J Emerg Med 2023; 30:202-204. [PMID: 37103897 DOI: 10.1097/mej.0000000000000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
| | - Sian Edwards
- Emergency Department, Whipps Cross Hospital, Barts Health NHS Trust
| | - Ben Bloom
- Emergency Department, Royal London Hospital, Barts Health NHS Trust
- Blizard Institute, Queen Mary University of London, London
| | - Nicholas Moore
- Emergency Department, Bristol Royal Infirmary, University Hospital Bristol and Weston NHS Trust, Bristol, UK
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Findakly S, Zia A, Kavnoudias H, Mathew J, Varma D, Di Muzio B, Lee R, Moriarty HK, Joseph T, Clements W. The use of whole-body trauma CT should be based on mechanism of injury: A risk analysis of 3920 patients at a tertiary trauma centre. Injury 2023:110828. [PMID: 37225543 DOI: 10.1016/j.injury.2023.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 04/27/2023] [Accepted: 05/13/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Mechanism of injury (MOI) plays a significant role in a decision to perform whole-body computed tomography (CT) imaging for trauma patients. Various mechanisms have unique patterns of injury and therefore form an important variable in decision making. METHODS Retrospective cohort study including all patients >18 years old who received a whole-body CT scan between 1 January 2019 and 19 February 2020. The outcomes were divided into CT 'positive' if any internal injuries were detected and CT 'negative' if no internal injuries were detected. The MOI, vital sign parameters, and other relevant clinical examination findings at presentation were recorded. RESULTS 3920 patients met the inclusion criteria, of which 1591 (40.6%) had a positive CT. The most common MOI was fall from standing height (FFSH), accounting for 23.0%, followed by motor vehicle accident (MVA), accounting for 22.4%. Covariates significantly associated with a positive CT included age, MVA >60 km/h, motor bike, bicycle, or pedestrian accident >30 km/h, prolonged extrication >30 min, fall from height above standing, penetrating chest or abdominal injury, as well as hypotension, neurological deficit, or hypoxia on arrival. FFSH was shown to reduce the risk of a positive CT overall, however, sub-analysis of FFSH in patients >65 years showed a significant association with a positive CT (OR 2.34, p < 0.001) compared to <65 years. CONCLUSIONS Pre-arrival information including MOI and vital signs have significant impact on identifying subsequent injuries with CT imaging. In high energy trauma, we should consider the need for whole-body CT based on MOI alone regardless of the clinical examination findings. However, for low-energy trauma, including FFSH, in the absence of clinical examination findings which support an internal injury, a screening whole-body CT is unlikely to yield a positive result, particularly in the age group <65yo.
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Affiliation(s)
- Salam Findakly
- Department of Radiology, Alfred Health, Melbourne, Australia. https://twitter.com/https//twitter.comSalamfindalky
| | - Adil Zia
- Department of Radiology, Alfred Health, Melbourne, Australia. https://twitter.com/https//twitter.comAdilFZia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia
| | - Joseph Mathew
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia; Department of Trauma, Alfred Health, Melbourne, Australia. https://twitter.com/https//twitter.comtrauma_jm
| | - Dinesh Varma
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia; National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia
| | - Bruno Di Muzio
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Robin Lee
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Heather K Moriarty
- Department of Radiology, Cork University Hospital, Cork, Ireland. https://twitter.com/https//twitter.comHeatherKateIR
| | - Tim Joseph
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia; National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia.
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Di Francesco ME, Magunia H, Örgel A, Tatagiba M, Radwan M, Adib SD. Case report: Interdisciplinary treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease requiring bypass surgery. Front Surg 2023; 10:1123947. [PMID: 37260599 PMCID: PMC10228685 DOI: 10.3389/fsurg.2023.1123947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/25/2023] [Indexed: 06/02/2023] Open
Abstract
Background Acute myocardial infarction (MI) frequently leads to consciousness disturbance following hemodynamic collapse. Therefore, MI can occur together with upper cervical spine trauma. Herein, we report the successful treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease (CAD). Case presentation A 70-year-old patient presented in our emergency outpatient clinic after a hemodynamic collapse without neurological deficits or heart-related complaints. Computed tomography (CT) scan of the cervical spine revealed a dislocated odontoid fracture Anderson and D'Alonzo type II and an unstable Gehweiler type III injury (Jefferson's fracture). An intradiploic arachnoid cyst in the posterior wall of the posterior fossa was a coincident radiological finding. Furthermore, coronary angiography confirmed three-vessel CAD with high-grade coronary artery stenosis. Indication for upper cervical spine surgery and bypass surgery was given. An interdisciplinary team of neurosurgeons, cardiothoracic surgeons and anesthesiologists evaluated the patient's case to develop the most suitable therapy concept and alternative strategies. Finally, in first step, C1-C2 fusion was performed by Harms technique under general anesthesia with x-ray guidance, spinal neuronavigation, Doppler ultrasound and cardiopulmonary monitoring. Cardiothoracic surgeons were on standby. One month later bypass surgery was performed uneventfully. Follow-up CT scan of cervical spine revealed intraosseous screw positioning and beginning fusion of the fractures. The patient did not develop neurological deficits and recovered completely from both surgeries. Conclusions Treating complex C1/C2 fractures with concomitant severe CAD requiring treatment is challenging and carries a high risk of complications. To our knowledge, the literature does not provide any guidelines regarding therapy of this constellation. To receive upper cervical spine stability and to prevent both, spinal cord injury and cardiovascular complications, an individual approach is required. Interdisciplinary cooperation to determine optimal therapeutic algorithms is needed.
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Affiliation(s)
| | - H. Magunia
- Department of Anesthesiology and Intensive Care Medicine, University of Tuebingen, Tuebingen, Germany
| | - A. Örgel
- Department of Diagnostic and Interventional Neuroradiology, University of Tuebingen, Tuebingen, Germany
| | - M. Tatagiba
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - M. Radwan
- Department of Thoracic and Cardiovascular Surgery, University of Tuebingen, Tuebingen, Germany
| | - S. D. Adib
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
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24
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Rutsch N, Amrein P, Exadaktylos AK, Benneker LM, Schmaranzer F, Müller M, Albers CE, Bigdon SF. Cervical spine trauma - Evaluating the diagnostic power of CT, MRI, X-Ray and LODOX. Injury 2023:S0020-1383(23)00401-1. [PMID: 37164902 DOI: 10.1016/j.injury.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/01/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Traumatic cervical spine (c-spine) injuries account for 10% of all spinal injuries. The c-spine is prone to injury by blunt acceleration/deceleration traumas. The Canadian C-Spine rule and NEXUS criteria guide clinical decision-making but lack consensus on imaging modality when necessary. This study aims to evaluate the sensitivity and specificity of CT, MRI, X-Ray, and, for the first time, LODOX-Statscan in identifying c-spine injuries in patients with blunt trauma and neck pain. METHODS We conducted a retrospective monocenter cohort study using patient data from the emergency department at Inselspital, Bern, Switzerland's largest level one trauma center. We identified patients presenting with trauma and neck pain during the recruitment period from 01.01.2012 to 31.12.2017. We included all patients that required a radiographic c-spine evaluation according to the NEXUS criteria. Certified spine surgeons reviewed each case, analyzed patient demographics, injury classification, trauma mechanism, and emergency management. The retrospective full case review was established as gold standard to decide whether the c-spine was injured. Sensitivity and specificity were calculated for CT, MRI, LODOX, and X-Ray imaging methods. RESULTS We identified 4996 patients, of which 2321 met the inclusion criteria. 91.3% (n = 2120) patients received a CT scan, 8.9% (n = 206) a MRI, 9.3% (n = 215) an X-ray, and 21.5% (n = 498) a LODOX scan. By retrospective case review, 186 participants were classified as injured. The sensitivity of CT was 88.6% (specificity 99%), and 89.8% (specificity 99.2%) with orthopedic surgeon consultation. MRI had a sensitivity of 88.5% (specificity of 96.9%); highlighting 14 cases correctly diagnosed as injured by MRI and misdiagnosed by CT. Projection radiography (36.4% sensitivity, 95.1% specificity) and LODOX (5.3% sensitivity, 100% specificity) were unsuitable for ruling out spinal injury. CONCLUSION While CT offers high sensitivity for detecting traumatic c-spine injury, MRI holds clinical significance in revealing injuries not recognized by CT in symptomatic patients. LODOX and projection radiography are insufficient for accurately ruling out c-spine injury. For patients with neurological symptoms, we recommend extended MRI use when CT scans are negative.
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Affiliation(s)
- Niklas Rutsch
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, Freiburgstrasse 3010, Bern, Switzerland
| | - Pascale Amrein
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, Freiburgstrasse 3010, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Freiburgstrasse 3010, Bern, Switzerland
| | - Lorin M Benneker
- Spine Service, Orthopedic Department, Sonnenhofspital, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Radiology, Inselspital, Bern University Hospital, Freiburgstrasse 3010, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Freiburgstrasse 3010, Bern, Switzerland
| | - Christoph E Albers
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, Freiburgstrasse 3010, Bern, Switzerland
| | - Sebastian F Bigdon
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, Freiburgstrasse 3010, Bern, Switzerland.
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25
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Rao D, Godreau JP, Jenson M, Rahmathulla G, Fiester P, Patel J, Hernandez M. Can Anterior Osteophyte Fractures Be Distinguished From Fracture Mimics in the Subaxial Cervical Spine? A Retrospective Analysis Evaluating Reported Fractures With Clinical Management Correlation. J Comput Assist Tomogr 2023; 47:460-466. [PMID: 37185011 DOI: 10.1097/rct.0000000000001445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE This study aimed to retrospectively distinguish true- from false-positive fractures of anterior subaxial cervical osteophytes, which were reported on noncontrast computed tomography reports, and to correlate the imaging findings with patient symptoms and analyze the downstream impact on management of both true and false positive fractures. METHODS A total of 127 patients had computed tomography reports of anterior osteophyte fractures. Radiology reports and imaging studies were evaluated to distinguish true fractures from fracture mimics. We analyzed imaging features including rigid spine (RS), prevertebral soft tissue swelling (PVSTS), and instability. We categorized symptoms and examination findings into 3 groups (0, asymptomatic; 1, neck pain; 2, neurological symptoms). Management was categorized into 3 groups (0, no treatment; 1, external bracing; 2, surgery). Associations between imaging features, fracture classification, clinical symptoms, magnetic resonance imaging utilization, and management were calculated using χ2 with Cramer V test to determine effect size. RESULTS Eighty patients had false-positive fractures, and 47 were true positive. There were significant associations between magnetic resonance imaging utilization and fracture classification (P ≤ 0.001), PVSTS (P ≤ 0.005), patient symptoms (P ≤ 0.001), and patient management (P ≤ 0.001). There were significant associations between patient management and fracture classification (P ≤ 0.001), patient symptoms (P ≤ 0.001), PVSTS (P ≤ 0.001), imaging findings of instability (P ≤ 0.001), and RS (P ≤ 0.021). There were significant associations between fracture classification and patient symptoms (P ≤ 0.045), and RS (P ≤ 0.006). CONCLUSIONS Subaxial isolated anterior osteophyte fractures fell into 3 major categories. By our methodology, if a suspected fracture was determined to be a fracture mimic in an asymptomatic patient, it was unlikely to be clinically significant. Isolated anterior osteophyte fractures without neurological symptoms or more concerning imaging findings can be treated conservatively. Finally, fractures that demonstrate indirect signs of instability or are associated with RS are more associated with surgical management.
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Affiliation(s)
| | | | | | - Gazanfar Rahmathulla
- Department of Neurosurgery, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
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26
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Osterhoff G, Scholz M, Disch AC, Katscher S, Spiegl UJA, Schnake KJ, Scheyerer MJ. Geriatric Odontoid Fractures: Treatment Algorithms of the German Society for Orthopaedics and Trauma Based on Expert Consensus and a Systematic Review. Global Spine J 2023; 13:13S-21S. [PMID: 37084350 PMCID: PMC10177304 DOI: 10.1177/21925682231157316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Systematic review/expert consensus. OBJECTIVES Fractures of the axis represent the most frequent injury of the spine in elderly patients. Both, operative and non-operative treatment are associated with a high rate of complications and mortality. The aim of this article was to summarize the current literature on the management of odontoid fractures in geriatric patients and to weigh it based on an expert consensus process. METHODS In a joint consensus process, members of the Spine Section of the German Orthopaedic and Trauma Society (DGOU) aimed to formulate recommendations for the diagnostic workup and treatment of odontoid fractures in geriatric patients. Based on the previously published recommendations, this article is an updated version with incorporating a systematic review of the recent literature. RESULTS Based on the new data available, the recommendations established in the initial consensus process were adapted. CONCLUSIONS Computed tomography represents the diagnostic standard for patients with suspected injuries of the upper cervical spine. Anderson/D'Alonzo odontoid fractures type 1, non-displaced type 2, and type 3 can be treated conservatively. Even non-unions do not necessarily result in poor clinical outcome. In Anderson/D'Alonzo type 2 fractures, surgical therapy offers the advantage of relatively safe osseous healing with no increased complication rate even in elderly patients and can thus be recommended. In very high aged patients, however, a case-by-case decision should be made. When surgical stabilization of osteoporotic odontoid fractures is indicated, posterior techniques are biomechanically advantageous and can be considered the standard.
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Affiliation(s)
- Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Matti Scholz
- ATOS Orthopaedic Clinic Braunfels, Braunfels, Germany
| | - Alexander C Disch
- University Comprehensive Spine Center (UCSC), University Center for Orthopaedics, Traumatology & Plastic Surgery, University Hospital Carl Gustav Carus at the TU Dresden, Germany
| | - Sebastian Katscher
- Interdisciplinary Center for Spine and Neurotrauma, Sana Klinikum Borna, Borna, Germany
| | - Ulrich J A Spiegl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Waldkrankenhaus Erlangen, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Max J Scheyerer
- Department of Orthopaedics and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Koln, Germany
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27
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Baker R, Klim S, Poonian J, Ritchie P, Ng S, Kelly AM. SOFTLY: Comparison of outcomes of rigid versus soft collar during emergency department investigation for potential cervical spine injury in low-risk blunt trauma patients - A pilot study. Emerg Med Australas 2023. [PMID: 36914237 DOI: 10.1111/1742-6723.14195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 01/29/2023] [Accepted: 02/20/2023] [Indexed: 03/15/2023]
Abstract
OBJECTIVE Blunt trauma patients with potential cervical spine injury are traditionally immobilised in rigid collars. Recently, this has been challenged. The present study's objective was comparison of the rate of patient-oriented adverse events in stable, alert, low-risk patients with potential cervical spine injuries immobilised in rigid versus soft collars. METHODS Unblinded, prospective quasi-randomised clinical trial of neurologically intact, adult, blunt trauma patients assessed as having potential cervical spine injury. Patients were randomised to collar type. All other aspects of care were unchanged. Primary outcome was patient-reported discomfort related to neck immobilisation by collar type. Secondary outcomes included adverse neurological events, agitation and clinically important cervical spine injuries (clinical trial registration number: ACTRN12621000286842). RESULTS A total of 137 patients were enrolled: 59 patients allocated to a rigid collar and 78 to a soft collar. Most injuries were from a fall <1 m (54%) or a motor vehicle crash (21.9%). Median neck pain score of collar immobilisation was lower in the soft collar group (3.0 [interquartile range 0-6.1] vs 6.0 [interquartile range 3-8.8], P < 0.001). The proportion of patients with clinician-identified agitation was lower in the soft collar group (5% vs 17%, P = 0.04). There were four clinically important cervical spine injuries (two in each group). All were treated conservatively. There were no adverse neurological events. CONCLUSIONS Use of soft rather than rigid collar immobilisation for low-risk blunt trauma patients with potential cervical spine injury is significantly less painful for patients and results in less agitation. A larger study is needed to determine the safety of this approach or whether collars are required at all.
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Affiliation(s)
- Robert Baker
- Emergency Department, Western Health, Melbourne, Victoria, Australia
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne, Victoria, Australia
| | - Jasmine Poonian
- Emergency Department, Western Health, Melbourne, Victoria, Australia
| | - Peter Ritchie
- Emergency Department, Western Health, Melbourne, Victoria, Australia
| | - Stephanie Ng
- Emergency Department, Western Health, Melbourne, Victoria, Australia
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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28
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Cerillo JL, Becsey AN, Sanghadia CP, Root KT, Lucke-Wold B. Spine Bracing: When to Utilize-A Narrative Review. BIOMECHANICS (BASEL, SWITZERLAND) 2023; 3:136-154. [PMID: 36949902 PMCID: PMC10029751 DOI: 10.3390/biomechanics3010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Spinal bracing is a common non-surgical technique that allows clinicians to prevent and correct malformations or injuries of a patient's spinal column. This review will explore the current standards of practice on spinal brace utilization. Specifically, it will highlight bracing usage in traumatic injuries, pregnancy, pediatrics, osteoporosis, and hyperkyphosis; address radiological findings concurrent with brace usage; and provide an overview of the braces currently available and advancements in the field. In doing so, we aim to improve clinicians' understanding and knowledge of bracing in common spinal pathologies to promote their appropriate use and improve patient outcomes.
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Affiliation(s)
- John L. Cerillo
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Clearwater, FL 33759, USA
| | | | - Chai P. Sanghadia
- Department of Molecular and Cellular Biology, University of Arizona, Tucson, AZ 85721, USA
| | - Kevin T. Root
- College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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29
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McCallum J, Eagles D, Ouyang Y, Ende JV, Vaillancourt C, Fehlmann C, Shorr R, Taljaard M, Stiell I. Cervical spine injuries in adults ≥ 65 years after low-level falls - A systematic review and meta-analysis. Am J Emerg Med 2023; 67:144-155. [PMID: 36893628 DOI: 10.1016/j.ajem.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/10/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Adults ≥ 65 are at risk of cervical spine (C-spine) injury, even after low-level falls. The objectives of this systematic review were to determine the prevalence of C-spine injury in this population and explore the association of unreliable clinical exam with C-spine injury. METHODS We conducted this systematic review according to PRISMA guidelines. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic reviews to include studies reporting on C-spine injury in adults ≥ 65 years after low-level falls. Two reviewers independently screened articles, abstracted data, and assessed bias. Discrepancies were resolved by a third reviewer. A meta-analysis was performed to estimate overall prevalence and the pooled odds ratio for the association between C-spine injury and an unreliable clinical exam. RESULTS The search identified 2044citations, 138 full texts were screened, and 21 studies were included in the systematic review. C-spine injury prevalence in adults ≥ 65 years after low-level falls was 3.8% (95% CI: 2.8-5.3). The odds of c-spine injury in those with altered level of consciousness (aLOC) v/s not aLOC was 1.21 (0.90-1.63) and in those with GCS < 15 v/s GCS 15 was 1.62 (0.37-6.98). Studies were at a low-risk of bias, although some had low recruitment and significant loss to follow-up. CONCLUSIONS Adults ≥ 65 years are at risk of cervical spine injury after low-level falls. More research is needed to determine whether there is an association between cervical spine injury and GCS < 15 or altered level of consciousness.
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Affiliation(s)
- Jessica McCallum
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Debra Eagles
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
| | - Yongdong Ouyang
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Jamie Vander Ende
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
| | - Christian Vaillancourt
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
| | - Christophe Fehlmann
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva CH-1211, Switzerland.
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Ian Stiell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
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30
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Lau L, Ajzenberg H, Haas B, Wong CL. Trauma in the Aging Population. Emerg Med Clin North Am 2023; 41:183-203. [DOI: 10.1016/j.emc.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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31
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Implementation of the Modified Canadian C-Spine Rule by Paramedics. Ann Emerg Med 2023; 81:187-196. [PMID: 36328852 DOI: 10.1016/j.annemergmed.2022.08.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/26/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE The Canadian C-spine rule was modified and validated for use by the paramedics in a multicenter study where patients were assessed with the Canadian C-spine rule yet all transported with immobilization. This study evaluated the clinical impact of the modified Canadian C-spine rule when implemented by paramedics. METHODS This single-center prospective cohort implementation study took place in Ottawa, Canada (from 2011 to 2015). Advanced and primary care paramedics were trained to use the modified Canadian C-spine rule, collect data on a standardized study form, and selectively transport eligible patients without immobilization. We evaluated all consecutive low-risk adult patients (Glasgow Coma Scale [GCS] 15, stable vital signs) at risk for a neck injury. We followed all patients without initial radiologic evaluation for 30 days. Analyses included descriptive statistics with 95% confidence intervals (CI), sensitivity, specificity, and kappa coefficients. RESULTS The 4,034 enrolled patients had a mean age of 43 (range 16 to 99), and 53.4% were female. Motor vehicle collisions were the most common mechanism of injury (55.1%), followed by falls (23.9%). There were 11 clinically important injuries. The paramedics classified these injuries with a sensitivity of 90.9% (95% CI, 58.7 to 99.8) and specificity of 66.5% (95% CI, 65.1 to 68.0). There was no adverse event or resulting spinal cord injury. The kappa agreement between paramedics and investigators was 0.94. A total of 2,583 (64.0%) immobilizations were avoided using the modified Canadian C-spine rule. CONCLUSION Paramedics could accurately apply the modified Canadian C-spine rule to low-risk trauma patients and significantly reduce the need for spinal immobilization during transport. This resulted in no adverse event or any spinal cord injury.
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Thom O, Roberts K, Leggat PA, Devine S, Peden AE, Franklin R. Cervical spine immobilisation is only required in drowning patients at high risk of axial loading of the spine. Emerg Med Australas 2023; 35:18-24. [PMID: 35878883 PMCID: PMC10087421 DOI: 10.1111/1742-6723.14036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/22/2022] [Accepted: 06/03/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Wave forced impacts are known to result in cervical spine injuries (CSI) and approximately 20% of drownings in Australia occur at the beach. The most common mechanism of injury in studies examining the frequency of CSI in drowning patients is shallow water diving. The aim of the present study was to determine what proportion of CSIs occurring in bodies of water experienced a concomitant drowning injury in a location where wave forced impacts are likely to be an additional risk factor. METHODS Electronic medical records at the Sunshine Coast Hospital and Health Service EDs, Queensland Ambulance Service case records and Surf Life Saving Queensland data between 1 January 2015 and 21 April 2021 were manually linked. Outcomes recorded included victim demographics, scene information, hospital course and patient disposition. RESULTS Ninety-one of 574 (15.9%) CSIs occurred in a body of water with risk of drowning. However, only 4 (4.3%) had a simultaneous drowning injury, representing 0.8% (4/483) of drowning presentations. Ten (10.9%) patients reported loss of consciousness, including the four with drowning. The principal mechanism of CSI was a wave forced impact (71/91, 78%). Most injuries occurred at the beach (79/91, 86.8%). Delayed presentation was common (28/91, 31%). A history of axial loading was 100% sensitive when indicating imaging. CONCLUSIONS The combination of CSI and drowning is uncommon. Cervical spine precautions are only required in drowning patients with signs or a history, or at high risk of, axial loading of the spine. This paper supports the move away from routine cervical spine precautions even in a high-risk population.
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Affiliation(s)
- Ogilvie Thom
- Department of Emergency Medicine, Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia.,College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.,Surf Life Saving Queensland, Brisbane, Queensland, Australia
| | - Kym Roberts
- Department of Emergency Medicine, Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia.,College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Peter A Leggat
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.,School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Susan Devine
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Amy E Peden
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.,Royal Life Saving Society Australia, Sydney, New South Wales, Australia.,School of Population Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Richard Franklin
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.,Royal Life Saving Society Australia, Sydney, New South Wales, Australia
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Hofstetter P, Schröder H, Beckers SK, Borgs C, Rossaint R, Felzen M. Immobilization in Emergency Medical Service - Are CSR and NEXUS-Criteria Considered? A Matched-Pairs Analysis Between Trauma Patients Treated by Onsite EMS Physicians and Patients Treated by Tele-EMS Physicians. Open Access Emerg Med 2023; 15:145-155. [PMID: 37187612 PMCID: PMC10178902 DOI: 10.2147/oaem.s386650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 03/28/2023] [Indexed: 05/17/2023] Open
Abstract
Background The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over- as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS- and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device. Methods A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter. Results Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard. Conclusion It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS- and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.
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Affiliation(s)
- Paula Hofstetter
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Department of Anesthesiology, Rhein-Maas Klinikum, Würselen, Germany
| | - Hanna Schröder
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany
| | - Stefan K Beckers
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany
- Medical Direction of Aachen Fire Department, Aachen, Germany
| | - Christina Borgs
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marc Felzen
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany
- Medical Direction of Aachen Fire Department, Aachen, Germany
- Correspondence: Marc Felzen, Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany, Tel +49 241 8088179, Fax +49 241 82406, Email
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Lo YH. Not as stiff as bamboo. HONG KONG J EMERG ME 2022. [DOI: 10.1177/10249079221143303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Yat Hei Lo
- Accident & Emergency Department, Prince of Wales Hospital, Shatin, Hong Kong
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Geduld C, Muller H, Saunders CJ. Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: A scoping review. Afr J Emerg Med 2022; 12:393-405. [PMID: 36187075 PMCID: PMC9489745 DOI: 10.1016/j.afjem.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 12/01/2022] Open
Abstract
There is a need for a patient-centred approach to the prehospital spinal management approach, which considers the associated risks, available personnel and limited resources. There is limited evidence supporting the use of the NEXUS and CCR decision tools in the prehospital setting. Prehospital spinal motion restriction decision tools should focus on reducing unnecessary spinal motion restriction and its associated adverse effects Developing a decision tool with more context-specific prehospital instructions for selective spinal motion restriction is of value.
Introduction The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners. Method We performed a focused scoping review of published literature on the prehospital use of clinical c-spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis. Results Following screening, forty-two articles were included in this scoping review. No studies conducted specifically in low resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting. Conclusion This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety, and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation, and a lack of context-specific evidence. These may provide important considerations for future guideline development.
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Affiliation(s)
- Charlene Geduld
- Division of Emergency Medicine, University of Cape Town, F51 Old Main Building, Groote Schuur Hospital, Observatory, South Africa
- Emergency Medical Care, Department of Clinical Science, Central University of Technology, Emergency Medical Care Building, 1 President Brand Street, Bloemfontein, South Africa
- Corresponding authors.
| | - Henra Muller
- Radiography, Department of Clinical Sciences, Central University of Technology, Prosperitas Building, 1 President Brand Street, Bloemfontein, South Africa
| | - Colleen J. Saunders
- Division of Emergency Medicine, University of Cape Town, F51 Old Main Building, Groote Schuur Hospital, Observatory, South Africa
- Corresponding authors.
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Practice patterns after implementation of a selective spinal immobilization protocol in a regional trauma system. J Trauma Acute Care Surg 2022; 93:806-812. [PMID: 35234714 DOI: 10.1097/ta.0000000000003589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Universal spinal immobilization has been the standard of prehospital trauma care since the 1960s. Selective immobilization has been shown to be safe and effective for emergency medical services use, but it is unclear whether such protocols reduce unnecessary and potentially harmful immobilization practices. This study evaluated the impact of a selective spinal immobilization protocol on practice patterns in a regional trauma system. METHODS All encounters for traumatic injury in the Tidewater Emergency Medical Services region from 2010 to 2016 were extracted from the Virginia Pre-Hospital Information Bridge. An interrupted time series analysis was used to assess practice change after system-wide protocol implementation in 2013. Intravenous access was used as a nonequivalent outcome measure in the absence of an appropriate control group. RESULTS A total of 63,981 encounters were analyzed. At baseline, 16.7% of patients underwent full immobilization. The preprotocol slope was slightly positive (0.2% per month; 95% confidence interval, 0.1-0.2%). Slope and level changes after protocol implementation did not differ from those observed for intravenous access (-0.4% vs. -0.4% per month [ p = 0.4917] and -1.6% vs. -1.1% [ p = 0.1202], respectively). Cervical spinal immobilization became more common over the postimplementation period (0.1% per month; 95% confidence interval, 0.1-0.1%). Rates of immobilization for isolated penetrating trauma remained unchanged. CONCLUSION Implementation of a selective spinal immobilization protocol did not reduce prehospital immobilization rates in a regional trauma system. Given the entrenched nature of immobilization practices, more intensive education and training strategies are needed. Efforts should prioritize eliminating immobilization for isolated penetrating trauma given its association with increased mortality. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Bäcker HC, Elias P, Braun KF, Johnson MA, Turner P, Cunningham J. Cervical immobilization in trauma patients: soft collars better than rigid collars? A systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3378-3391. [PMID: 36181555 DOI: 10.1007/s00586-022-07405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Rigid cervical spine following trauma immobilization is recommended to reduce neurological disability and provide spinal stability. Soft collars have been proposed as a good alternative because of the complications related to rigid collars. The purpose of this study was to perform a systematic review on soft and rigid collars in the prehospital management of cervical trauma. METHOD A systematic review was performed following the PRISMA guidelines. Search terms were (immobilization) AND (collar) AND ((neck) OR (cervical)) to evaluate the range of motion (ROM) and evidence of clinical outcome for soft and rigid collars. RESULTS A total of 18 studies met eligibility criteria including 2 clinical studies and 16 articles investigating the range of motion (ROM). Four hundred and ninety-six patients at a mean age of 32.5 years (SD 16.8) were included. Measurements were performed in a seated position in twelve studies. Eight articles reported the ROM without a collar, 7 with a soft collar, and 15 with a rigid collar. There was no significant difference in flexion/extension, bending and rotation following immobilization with soft collars compared to no collar. Rigid collars provided significantly higher stability compared to no collar (p < 0.005) and to soft collars in flexion/extension and rotation movements (p < 0.05). The retrospective clinical studies showed no significant differences in secondary spinal cord injuries for soft collar (0.5%) and for rigid collar (1.1%). One study, comparing immobilization without a collar compared to that with a rigid collar, found a significant difference in neurologic deficiency and supraclavicular nerve lesion. CONCLUSION Although rigid collars provide significant higher stability to no collar and to soft collars in flexion/ extension and rotation movements, clinical studies could not confirm a difference in neurological outcome. LEVEL OF EVIDENCE II, Systematic Review.
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Affiliation(s)
- Henrik C Bäcker
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, USA. .,Epworth Hospital Richmond, 89 Bridge Road, Richmond, VIC, 3121, USA. .,Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Berlin, Germany.
| | - Patrick Elias
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, USA
| | - Karl F Braun
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Berlin, Germany.,Department of Trauma Surgery, Technical University Munich, Klinikum Rechts Der Isar, Munich, Germany
| | | | - Peter Turner
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, USA.,Epworth Hospital Richmond, 89 Bridge Road, Richmond, VIC, 3121, USA
| | - John Cunningham
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, USA.,Epworth Hospital Richmond, 89 Bridge Road, Richmond, VIC, 3121, USA
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Ugalde IT, Chaudhari PP, Badawy M, Ishimine P, McCarten-Gibbs KA, Yen K, Atigapramoj NS, Sage A, Nielsen D, Adelson PD, Upperman J, Tancredi D, Kuppermann N, Holmes JF. Validation of Prediction Rules for Computed Tomography Use in Children With Blunt Abdominal or Blunt Head Trauma: Protocol for a Prospective Multicenter Observational Cohort Study. JMIR Res Protoc 2022; 11:e43027. [PMID: 36422920 PMCID: PMC9732756 DOI: 10.2196/43027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/09/2022] [Accepted: 11/12/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Traumatic brain injuries (TBIs) and intra-abdominal injuries (IAIs) are 2 leading causes of traumatic death and disability in children. To avoid missed or delayed diagnoses leading to increased morbidity, computed tomography (CT) is used liberally. However, the overuse of CT leads to inefficient care and radiation-induced malignancies. Therefore, to maximize precision and minimize the overuse of CT, the Pediatric Emergency Care Applied Research Network (PECARN) previously derived clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma in large cohorts of children who are injured. OBJECTIVE This study aimed to validate the IAI and age-based TBI clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma. METHODS This was a prospective 6-center observational study of children aged <18 years with blunt torso or head trauma. Consistent with the original derivation studies, enrolled children underwent routine history and physical examinations, and the treating clinicians completed case report forms prior to knowledge of CT results (if performed). Medical records were reviewed to determine clinical courses and outcomes for all patients, and for those who were discharged from the emergency department, a follow-up survey via a telephone call or SMS text message was performed to identify any patients with missed IAIs or TBIs. The primary outcomes were IAI undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries) and clinically important TBI (death from TBI, neurosurgical procedure, intubation for >24 hours for TBI, or hospital admission of ≥2 nights due to a TBI on CT). Prediction rule accuracy was assessed by measuring rule classification performance, using standard point and 95% CI estimates of the operational characteristics of each prediction rule (sensitivity, specificity, positive and negative predictive values, and diagnostic likelihood ratios). RESULTS The project was funded in 2016, and enrollment was completed on September 1, 2021. Data analyses are expected to be completed by December 2022, and the primary study results are expected to be submitted for publication in 2023. CONCLUSIONS This study will attempt to validate previously derived clinical prediction rules to accurately identify children at high and very low risk for clinically important IAIs and TBIs. Assuming successful validation, widespread implementation is then indicated, which will optimize the care of children who are injured by better aligning CT use with need. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/43027.
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Affiliation(s)
- Irma T Ugalde
- Department of Emergency Medicine, Children's Memorial Hermann Hospital, McGovern Medical School at UTHealth Houston, Houston, TX, United States
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Mohamed Badawy
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States
| | - Paul Ishimine
- Department of Emergency Medicine and Pediatrics, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, CA, United States
| | - Kevan A McCarten-Gibbs
- Department of Emergency Medicine, University of California San Francisco Benioff Children's Hospital, Oakland, CA, United States
| | - Kenneth Yen
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States
| | - Nisa S Atigapramoj
- Department of Emergency Medicine, University of California San Francisco Benioff Children's Hospital, Oakland, CA, United States
| | - Allyson Sage
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Donovan Nielsen
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - P David Adelson
- Barrow Neurological Institute of Phoenix Children's Hospital, Department of Child Health, Division of Pediatric Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ, United States
| | - Jeffrey Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Daniel Tancredi
- Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
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Kaewlai R, Chatpuwaphat J, Butnian K, Thusneyapan K, Panrong N, Lertpipopmetha W, Wongpongsalee T. Thoracic Inlet in Cervical Spine CT of Blunt Trauma Patients: Prevalence of Pathologies and Importance of CT Interpretation. TOMOGRAPHY (ANN ARBOR, MICH.) 2022; 8:2772-2783. [PMID: 36412690 PMCID: PMC9680416 DOI: 10.3390/tomography8060231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND The thoracic inlet of blunt trauma patients may have pathologies that can be diagnosed on cervical spine computed tomography (CT) but that are not evident on concurrent portable chest radiography (pCXR). This retrospective investigation aimed to identify the prevalence of thoracic inlet pathologies on cervical spine CT and their importance by measuring the diagnostic performance of pCXR and the predictive factors of such abnormalities. METHODS This investigation was performed at a level-1 trauma center and included CT and concurrent pCXR of 385 consecutive adult patients (280 men, mean age of 47.6 years) who presented with suspected cervical spine injury. CT and pCXR findings were independently re-reviewed, and CT was considered the reference standard. RESULTS Traumatic, significant nontraumatic and nonsignificant pathologies were present at 23.4%, 23.6% and 58.2%, respectively. The most common traumatic diagnoses were pneumothorax (12.7%) and pulmonary contusion (10.4%). The most common significant nontraumatic findings were pulmonary nodules (8.1%), micronodules (6.8%) and septal thickening (4.2%). The prevalence of active tuberculosis was 3.4%. The sensitivity and positive predictive value of pCXR was 56.67% and 49.51% in diagnosing traumatic and 8.89% and 50% in significant nontraumatic pathologies. No demographic or pre-admission clinical factors could predict these abnormalities. CONCLUSIONS Several significant pathologies of the thoracic inlet were visualized on trauma cervical spine CT. Since a concurrent pCXR was not sensitive and no demographic or clinical factors could predict these abnormalities, a liberal use of chest CT is suggested, particularly among those experiencing high-energy trauma with significant injuries of the thoracic inlet. If chest CT is not available, a meticulous evaluation of the thoracic inlet in the cervical spine CT of blunt trauma patients is important.
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Affiliation(s)
- Rathachai Kaewlai
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd., Bangkok Noi, Bangkok 10700, Thailand
| | - Jitti Chatpuwaphat
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd., Bangkok Noi, Bangkok 10700, Thailand
| | - Krittachat Butnian
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd., Bangkok Noi, Bangkok 10700, Thailand
| | - Kittipott Thusneyapan
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd., Bangkok Noi, Bangkok 10700, Thailand
| | - Nutthanun Panrong
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd., Bangkok Noi, Bangkok 10700, Thailand
| | - Wanicha Lertpipopmetha
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd., Bangkok Noi, Bangkok 10700, Thailand
| | - Thongsak Wongpongsalee
- Division of Trauma Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd., Bangkok Noi, Bangkok 10700, Thailand
- Correspondence: ; Tel.: +66-86-015-5915
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Vaccaro AR, Lambrechts MJ, Karamian BA, Canseco JA, Oner C, Benneker LM, Bransford R, Kandziora F, Shanmuganathan R, El-Sharkawi M, Kanna R, Joaquim A, Schnake K, Kepler CK, Schroeder GD. Global Validation of the AO Spine Upper Cervical Injury Classification. Spine (Phila Pa 1976) 2022; 47:1541-1548. [PMID: 35877555 PMCID: PMC9612701 DOI: 10.1097/brs.0000000000004429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/17/2022] [Accepted: 06/02/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Global cross-sectional survey. OBJECTIVE To determine the classification accuracy, interobserver reliability, and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on an international group of AO Spine members. SUMMARY OF BACKGROUND DATA Previous upper cervical spine injury classifications have primarily been descriptive without incorporating a hierarchical injury progression within the classification system. Further, upper cervical spine injury classifications have focused on distinct anatomical segments within the upper cervical spine. The AO Spine Upper Cervical Injury Classification System incorporates all injuries of the upper cervical spine into a single classification system focused on a hierarchical progression from isolated bony injuries (type A) to fracture dislocations (type C). METHODS A total of 275 AO Spine members participated in a validation aimed at classifying 25 upper cervical spine injuries through computed tomography scans according to the AO Spine Upper Cervical Classification System. The validation occurred on two separate occasions, three weeks apart. Descriptive statistics for percent agreement with the gold-standard were calculated and the Pearson χ 2 test evaluated significance between validation groups. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS The accuracy of AO Spine members to appropriately classify upper cervical spine injuries was 79.7% on assessment 1 (AS1) and 78.7% on assessment 2 (AS2). The overall intraobserver reproducibility was substantial (κ=0.70), while the overall interobserver reliability for AS1 and AS2 was substantial (κ=0.63 and κ=0.61, respectively). Injury location had higher interobserver reliability (AS1: κ = 0.85 and AS2: κ=0.83) than the injury type (AS1: κ=0.59 and AS2: 0.57) on both assessments. CONCLUSION The global validation of the AO Spine Upper Cervical Injury Classification System demonstrated substantial interobserver agreement and intraobserver reproducibility. These results support the universal applicability of the AO Spine Upper Cervical Injury Classification System. LEVEL OF EVIDENCE 4.
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Affiliation(s)
| | | | | | - Jose A. Canseco
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, the Netherlands
| | | | - Richard Bransford
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | | | | | | | - Rishi Kanna
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Andrei Joaquim
- Department of Neurology, Neurosurgery Division, State University of Campinas, Campinas, Sao Paulo, Brazil
| | - Klaus Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
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Dorfman JD. Near Hanging: Evaluation and Management. Chest 2022; 163:855-860. [PMID: 36372303 PMCID: PMC9647002 DOI: 10.1016/j.chest.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 11/03/2022] [Indexed: 11/12/2022] Open
Abstract
Prior to the COVID-19 pandemic, the incidence of self-harm was already on the rise. Hanging/suffocation accounted for 50% of the increase in suicide attempts and remains the second leading cause of death from self-harm in the United States. Studies on the management of near-hanging patients are lacking, and most published literature is retrospective. Following airway and circulation assessment, clinical examination and imaging, namely CT angiography, remain the standard for identifying the injuries associated with near hanging: cervical spine fracture, blunt cerebrovascular injury, laryngeal injury, and injury to the trachea and oropharynx. These injuries, however, are uncommon, and each occur in < 5% of patients in most series. In a large series of critically ill near-hanging patients, > 50% survived to hospital discharge; however, cardiac arrest predicted a poor outcome. The management of asphyxia-related arrest remains controversial. Targeted temperature management has only been studied in a single large multicenter trial, which was retrospective. Given the significant selection bias of targeted temperature management in the treatment of the most ill patients, no firm recommendations can be made. Finally, for survivors, the underlying mental health issues must be addressed to avoid recurrent suicide attempts. Thirty percent of patients in a large near-hanging series were admitted for their second suicide attempt.
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Affiliation(s)
- Jon D Dorfman
- Division of Trauma and Surgical Critical Care, UMass Memorial, Worcester, MA.
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Häske D, Blumenstock G, Hossfeld B, Wölfl C, Schweigkofler U, Stock JP. The Immo Traffic Light System as a Decision-Making Tool for Prehospital Spinal Immobilization. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:753-758. [PMID: 35978468 PMCID: PMC9853232 DOI: 10.3238/arztebl.m2022.0291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 01/24/2022] [Accepted: 07/21/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Spinal injuries are difficult injuries to assess yet can be associated with significant neurological damage. To avoid secondary damage, immobilization is considered state of the art trauma care. The indication for spinal immobilization must be assessed, however, for potential complications as well as its advantages and disadvantages. METHODS This systematic review addressing the question of the correct indication for spinal immobilization in trauma patients was compiled on the basis of our previously published analysis of possible predictors from the Trauma Registry of the German Society for Trauma Surgery. A Delphi procedure was then used to develop suggestions for action regarding immobilization based on the results of this review. RESULTS The search of the literature yielded 576 publications. The 24 publications included in the qualitative analysis report of 2 228 076 patients. A decision tool for spinal immobilization in prehospital trauma care was developed (Immo traffic light system) based on the results of the Delphi procedure. According to this system, severely injured patients with blunt trauma, severe traumatic brain injury, peripheral neurological symptoms, or spinal pain requiring treatment should be immobilized. Patients with a statistically increased risk of spinal injury as a result of the four cardinal features (fall >3m, severe trunk injury, supra clavicular injury, seniority [age >65 years]) should only have their spinal motion restricted after weighing up the pros and cons. Isolated penetrating trunk injuries should not be immobilized. CONCLUSION High-quality studies demonstrating the benefit of prehospital spinal immobilization are still lacking. Decision tools such as the Immo traffic light system can help weigh up the pros and cons of immobilization.
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Affiliation(s)
- David Häske
- Center for Public Health and Health Services Research, University Hospital of Tübingen, and German Red Cross Emergency Services Reutlingen,*Center for Public Health and Health Services Research University Hospital of Tübingen Osianderstr. 5 72076 Tübingen, Germany
| | - Gunnar Blumenstock
- Institute of Clinical Epidemiology and Applied Biometry, University Hospital of Tübingen
| | - Björn Hossfeld
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Federal Armed Forces Hospital of Ulm
| | - Christoph Wölfl
- Department for Orthopedic Surgery, Trauma and Sports Traumatology – Hand and Plastic Surgery, Musculoskeletal Center Neuwied, Marienhaus Hospital Neuwied
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Trauma Center, Frankfurt am Main
| | - Jan-Philipp Stock
- Department for Anesthesiology, Intensive Care Medicine, Emergency Medicine, Pain Therapy and Palliative Care, am Steinenberg Hospital, Reutlingen: Jan-Philipp Stock
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Mohai A, Gifford J, Herkt R, Parker A, Toder A, Dixon D, Kennedy E. A scoping review of cervical spine evaluation in standardised clinical concussion evaluation tools. Phys Ther Sport 2022; 57:95-104. [PMID: 35963133 DOI: 10.1016/j.ptsp.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND It can be a challenge for clinicians to evaluate trauma that could represent cervical spine injury, concussion, or both. These conditions share common mechanisms of injury and symptom profiles, yet distinct aetiology and management. In the clinical evaluation of concussion, a range of standardised tools are available but the extent to which such tools include cervical spine evaluation is unclear. OBJECTIVE To identify a variety of standardised clinical concussion evaluation tools, examine if these tools include cervical spine evaluation, and describe the characteristics of cervical spine evaluation included. To have an informed discussion about how cervical spine evaluation might best be approached after a concussion event. DESIGN Scoping review. METHOD A structured literature search was performed in eight databases to identify standardised clinical concussion evaluation tools. Each tool was then reviewed for cervical spine evaluation, and the characteristics of tools including cervical spine evaluation were described. RESULTS The structured search identified 82 standardised clinical concussion evaluation tools. Eleven tools included cervical spine assessment related primarily to the evaluation of red flags and symptoms, just three included physical examination. CONCLUSION Few standardised clinical concussion evaluation tools include cervical spine evaluation, and even fewer include physical examination. Cervical spine evaluation in concussion may benefit from closer alignment with established approaches to screening for clinically significant cervical spine injuries. In concussion, we advocate for an approach to cervical spine evaluation that includes screening for dangerous mechanisms of injury, neurological deficit, distracting injury and neck pain; and physical examination of neck range of motion and neck tenderness.
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Affiliation(s)
| | - Jack Gifford
- School of Physiotherapy, University of Otago, New Zealand
| | - Rebecca Herkt
- School of Physiotherapy, University of Otago, New Zealand
| | - Alexia Parker
- School of Physiotherapy, University of Otago, New Zealand
| | - Aiden Toder
- School of Physiotherapy, University of Otago, New Zealand
| | - Dave Dixon
- Southern District Health Board, New Zealand
| | - Ewan Kennedy
- School of Physiotherapy, University of Otago, New Zealand
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Bass GA, Stephen C, Forssten MP, Bailey JA, Mohseni S, Cao Y, Chreiman K, Duffy C, Seamon MJ, Cannon JW, Martin ND. Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury. J Surg Res 2022; 277:310-318. [DOI: 10.1016/j.jss.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/04/2022] [Accepted: 04/01/2022] [Indexed: 02/02/2023]
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Is It Possible to Replace Conventional Radiography (CR) with a Dose Neutral Computed Tomography (CT) of the Cervical Spine in Emergency Radiology—An Experimental Cadaver Study. Diagnostics (Basel) 2022; 12:diagnostics12081872. [PMID: 36010222 PMCID: PMC9406668 DOI: 10.3390/diagnostics12081872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/11/2022] Open
Abstract
The purpose of this experimental study on recently deceased human cadavers was to investigate whether (I) the radiation exposure of the cervical spine CT can be reduced comparable to a dose level of conventional radiography (CR); and (II) whether and which human body parameters can be predictive for higher dose reduction potential (in this context). Materials and Methods: Seventy serial CT scans of the cervical spine of 10 human cadavers undergoing postmortem virtual autopsy were taken using stepwise decreasing upper limits of the tube current (300 mAs, 150 mAs, 110 mAs, 80 mAs, 60 mAs, 40 mAs, and 20 mAs) at 120 kVp. An additional scan acquired at a fixed tube current of 300 mAs served as a reference. Images were reconstructed with filtered back projection and the upper (C1-4) and lower (C4-7) cervical spine were evaluated by three blinded readers for image quality, regarding diagnostic value and resolution of anatomical structures according to a semiquantitative three-point-scale. Dose values and individual physical parameters were recorded. The relationship of diagnostic IQ, dose reduction level, and patients’ physical parameters were investigated. The high-contrast resolution of the applied CT protocols was tested in an additional phantom study. Results: The IQ of the upper cervical spine was diagnostic at 1.69 ± 0.58 mGy (CTDI) corresponding to 0.20 ± 0.07 mSv (effective dose) in all cadavers. IQ of the lower cervical spine was diagnostic at 4.77 ± 1.86 mGy corresponding to 0.560 ± 0.21 mSv (effective dose) in seven cadavers and at 2.60 ± 0.93 mGy corresponding to 0.31 ± 0.11 mSv in four cadavers. Significant correlation was detected for BMI (0.8366; p = 0.002548) and the anteroposterior (a.p.) chest diameter (0.8363; p = 0.002566), shoulder positioning (0.79799; p = 0.00995), and radiation exposure. Conclusions: Conventional radiography can be replaced with a nearly dose-neutral CT scan of the cervical spine.
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Boonrod A, Boonrod A, Meethawolgul A, Twinprai P. Diagnostic accuracy of deep learning for evaluation of C-spine injury from lateral neck radiographs. Heliyon 2022; 8:e10372. [PMID: 36061007 PMCID: PMC9433686 DOI: 10.1016/j.heliyon.2022.e10372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/01/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background Materials and methods Results Conclusion
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Affiliation(s)
- Arunnit Boonrod
- Department of Radiology, Khon Kaen University, Khon Kaen, 40002, Thailand
- AI and Informatics in Medical Imaging (AIIMI) Research Group, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Artit Boonrod
- Department of Orthopedics, Khon Kaen University, Khon Kaen, 40002, Thailand
- AI and Informatics in Medical Imaging (AIIMI) Research Group, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Corresponding author.
| | | | - Prin Twinprai
- Department of Radiology, Khon Kaen University, Khon Kaen, 40002, Thailand
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Raja AS, Rodriguez RM, Gupta M, Isaacs ED, Kornblith LZ, Prabhakar A, Saillant N, Schmit PJ, Wei SH, Mower WR. Developing a decision instrument to guide abdominal-pelvic imaging of blunt trauma patients: Methodology and protocol of the NEXUS abdominal-pelvic imaging study. PLoS One 2022; 17:e0271070. [PMID: 35877687 PMCID: PMC9312398 DOI: 10.1371/journal.pone.0271070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/22/2022] [Indexed: 11/19/2022] Open
Abstract
Although computed tomography (CT) of the abdomen and pelvis (A/P) can provide crucial information for managing blunt trauma patients, liberal and indiscriminant imaging is expensive, can delay critical interventions, and unnecessarily exposes patients to ionizing radiation. Currently no definitive recommendations exist detailing which adult blunt trauma patients should receive A/P CT imaging and which patients may safely forego CT. Considerable benefit could be realized by identifying clinical criteria that reliably classify the risk of abdominal and pelvic injuries in blunt trauma patients. Patients identified as “very low risk” by such criteria would be free of significant injury, receive no benefit from imaging and therefore could be safely spared the expense and radiation exposure associated with A/P CT. The goal of this two-phase nationwide multicenter observational study is to derive and validate the use of clinical criteria to stratify the risk of injuries to the abdomen and pelvis among adult blunt trauma patients. We estimate that nation-wide implementation of a rigorously developed decision instrument could safely reduce CT imaging of adult blunt trauma patients by more than 20%, and reduce annual radiographic charges by $180 million, while simultaneously expediting trauma care and decreasing radiation exposure with its attendant risk of radiation-induced malignancy. Prior to enrollment we convened an expert panel of trauma surgeons, radiologists and emergency medicine physicians to develop a consensus definition for clinically significant abdominal and pelvic injury. In the first derivation phase of the study, we will document the presence or absence of preselected candidate criteria, as well as the presence or absence of significant abdominal or pelvic injuries in a cohort of blunt trauma victims. Using recursive partitioning, we will examine combinations of these criteria to identify an optimal “very low risk” subset that identifies injuries with a sensitivity exceeding 98%, excludes injury with a negative predictive value (NPV) greater than 98%, and retains the highest possible specificity and potential to decrease imaging. In Phase 2 of the study we will validate the performance of a decision rule based on these criteria among a new cohort of patients to ensure that the criteria retain high sensitivity, NPV and optimal specificity. Validating the sensitivity of the decision instrument with high statistical precision requires evaluations on 317 blunt trauma patients who have significant abdominal-pelvic injuries, which will in turn require evaluations on approximately 6,340 blunt trauma patients. We will estimate potential reductions in CT imaging by counting the number of abdominal-pelvic CT scans performed on “very low risk” patients. Reductions in charges and radiation exposure will be determined by respectively summing radiographic charges and lifetime decreases in radiation morbidity and mortality for all “very low risk” cases.
Trial registration: Clinicaltrials.gov trial registration number: NCT04937868.
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Affiliation(s)
- Ali S. Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Robert M. Rodriguez
- Department of Emergency Medicine, San Francisco General Hospital, UCSF School of Medicine, San Francisco, California, United States of America
| | - Malkeet Gupta
- Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California, United States of America
- Antelope Valley Hospital Emergency Department, Lancaster, California, United States of America
| | - Eric D. Isaacs
- Department of Emergency Medicine, San Francisco General Hospital, UCSF School of Medicine, San Francisco, California, United States of America
| | - Lucy Z. Kornblith
- Department of Surgery, San Francisco General Hospital, UCSF School of Medicine, San Francisco, California, United States of America
| | - Anand Prabhakar
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Noelle Saillant
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Paul J. Schmit
- UCLA Department of Surgery, Ronald Reagan UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California, United States of America
| | - Sindy H. Wei
- UCLA Department of Radiological Sciences, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States of America
| | - William R. Mower
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States of America
- * E-mail:
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Hattingh HL, Michaleff ZA, Fawzy P, Du L, Willcocks K, Tan KM, Keijzers G. Ordering of computed tomography scans for head and cervical spine: a qualitative study exploring influences on doctors' decision-making. BMC Health Serv Res 2022; 22:790. [PMID: 35717206 PMCID: PMC9206095 DOI: 10.1186/s12913-022-08156-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ordering of computed tomography (CT) scans needs to consideration of diagnostic utility as well as resource utilisation and radiation exposure. Several factors influence ordering decisions, including evidence-based clinical decision support tools to rule out serious disease. The aim of this qualitative study was to explore factors influencing Emergency Department (ED) doctors' decisions to order CT of the head or cervical spine. METHODS In-depth semi-structured interviews were conducted with purposively selected ED doctors from two affiliated public hospitals. An interview tool with 10 questions, including three hypothetical scenarios, was developed and validated to guide discussions. Interviews were audio recorded, transcribed verbatim, and compared with field notes. Transcribed data were imported into NVivo Release 1.3 to facilitate coding and thematic analysis. RESULTS In total 21 doctors participated in semi-structured interviews between February and December 2020; mean interview duration was 35 min. Data saturation was reached. Participants ranged from first-year interns to experienced consultants. Five overarching emerging themes were: 1) health system and local context, 2) work structure and support, 3) professional practices and responsibility, 4) reliable patient information, and 5) holistic patient-centred care. Mapping of themes and sub-themes against a behaviour change model provided a basis for future interventions. CONCLUSIONS CT ordering is complex and multifaceted. Multiple factors are considered by ED doctors during decisions to order CT scans for head or c-spine injuries. Increased education on the use of clinical decision support tools and an overall strategy to improve awareness of low-value care is needed. Strategies to reduce low-yield CT ordering will need to be sustainable, sophisticated and supportive to achieve lasting change.
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Affiliation(s)
- H Laetitia Hattingh
- Diagnostic and Sub-Specialty Services, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia. .,School of Pharmacy and Medical Sciences, Griffith University, Southport, Gold Coast, QLD, 4222, Australia.
| | | | - Peter Fawzy
- Neurosurgery Department, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia.,School of Medicine and Health Sciences, Bond University, Gold Coast, QLD, 4226, Australia
| | - Leanne Du
- Medical Imaging, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia
| | - Karlene Willcocks
- Diagnostic and Sub-Specialty Services, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia
| | - K Meng Tan
- Diagnostic and Sub-Specialty Services, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Health, Southport, Gold Coast, QLD, 4215, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, 4226, Australia.,School of Medicine, Griffith University, Southport, Gold Coast, QLD, 4222, Australia
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Randall MM, Egbert J, Ito BM, Yalung JE, Brown L. Outcomes of Patients With Negative Cervical Imaging but Persistent Neck Tenderness Discharged With a Rigid Collar After Trauma. Cureus 2022; 14:e24170. [PMID: 35592211 PMCID: PMC9110094 DOI: 10.7759/cureus.24170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction It is not uncommon for patients with persistent neck pain after trauma despite negative cervical imaging to be discharged with a rigid collar. Protocols for these patients vary widely. Few studies have evaluated clinical outcomes after discharge. No studies have evaluated the patient’s experience in a cervical collar after discharge. Methods We evaluated adults with blunt trauma and negative cervical spine imaging who were discharged in a rigid cervical collar. Over a 19-month period, 45 patients were available for analyses. The primary outcome was any identified missed injuries after discharge. Secondary outcomes were the incidence of patients self-clearing from their collars and complications related to wearing a collar. Results There were no missed traumatic injuries on follow-up imaging. Twenty of 45 patients cleared themselves from the collar without a physician order. Twenty-four patients had their collars removed by a provider in the clinic between 1-84 days after injury. One patient removed the collar after being advised by a chiropractor. More than half of patients reported one or more complications from wearing the cervical collar including pain, skin irritation, problems sleeping, difficulty talking or swallowing. Conclusions Collar complications are frequent. Follow-up imaging did not change outpatient management. Our data suggests against the practice of discharging trauma patients home in a cervical collar with negative imaging and no focal neurologic deficit.
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Halfpap J, Riebel L, Tognoni A, Coller M, Sheu RG, Rosenthal MD. Improving Access and Decreasing Healthcare Utilization for Patients With Acute Spine Pain: Five-Year Results of a Direct Access Clinic. Mil Med 2022; 188:usac064. [PMID: 35284938 DOI: 10.1093/milmed/usac064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/21/2022] [Accepted: 02/24/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Spine pain is one of the largest and costliest burdens to our healthcare systems. While evidence-based guidelines for spine pain have been established, and continue to evolve, the actual management of this condition continues to burden the healthcare system. This has led to increased costs due to inefficient entry to healthcare, utilization of treatments unsupported by clinical guidelines, and patient navigation through our healthcare systems. The purpose of this study was to assess the healthcare utilization and related outcomes for Active Duty Service Members (ADSM) receiving healthcare services in a novel acute spine pain clinic (ASPC) during the first 5 years of operation at a large Military Treatment Facility. MATERIALS AND METHODS In 2014 the Physical Medicine and Rehabilitation and Physical Therapy (PT) services designed a novel acute spine clinic intended to directly receive ADSM with acute spine symptoms for an initial evaluation by a Physical Therapist. The inclusion criteria into the ASPC were: ADSM, pain less than or equal to 7 days, no more than three prior episodes of acute spine pain in the past 3 years, and not currently receiving care from Chiropractic, Pain Management, or PT services. The exclusion criteria were: significant and/or progressive neurological deficits, bowel or bladder dysfunction, unstable vital signs or fever, hematuria or extensive trauma. RESULTS A total of 1,215 patients presented to the ASPC for evaluation between 2014 and 2019. The most common chief complaint was acute pain in the lumbar spine (73%), followed by cervical spine pain (15%), and thoracic spine pain (12%) represented the fewest. The average number of PT visits per patient was 3.5 (range 1-13) with 61.1% utilizing three or fewer visits. Over 95% of cases returned to work the same day as their initial evaluation. Sixty-six percent returned to work without restriction the same day as their initial evaluation. Light duty recommendations were provided to 412 (33.9%) patients ranging from one to 30 days, with greater than 85% of the light duty being less than 14 days. Recommendations to not return to work (sick-in-quarters) were issued to 56 (4.6%) patients. The sick-in-quarters recommendations were for a 24-hour period in 48 cases, 48 hours for seven cases, and 72 hours for one case. All encounters in which the patient first sought care at the ASPC for low back pain met the Healthcare Effectiveness Data Set standard for low back pain care of having no imaging within 28 days of the first encounter for nonspecific low back pain. A medical record review of 100 randomly selected patients within 12 months of the initial evaluation demonstrated decreased utilization of medication, imaging, and referral to surgical services. CONCLUSIONS This innovative approach demonstrates the potential benefits of rapid access to treatment and education for patients with acute spine pain by a Physical Therapist. Modeling this approach at Military Treatment Facilities may lead to decreased utilization of medications, radiology services, specialty care referrals, and reduced cost of care provided to individuals with acute spine pain.
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Affiliation(s)
- Josh Halfpap
- Bowling Green State University, College of Health and Human Services, Doctor of Physical Therapy Program, Bowling Green, OH, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Laura Riebel
- Sports Medicine and Rehabilitation Team, Naval Medical Readiness and Training Command Great Lakes, North Chicago, IL 60064, USA
| | - Angela Tognoni
- Department of Physical Therapy, Scripps Mercy Hospital San Diego, San Diego, CA 92103, USA
| | - Michael Coller
- Bowling Green State University, College of Health and Human Services, Doctor of Physical Therapy Program, Bowling Green, OH, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Robert G Sheu
- Department of Physical Medicine and Rehabilitation, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Michael D Rosenthal
- Doctor of Physical Therapy Program, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE 68198, USA
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