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Moody D, Showery J, Lador R, Hernandez I, Prasarn ML. Is Routine Use of External Spinal Orthoses Necessary After Operative Stabilization of Cervical Spine Injuries? Clin Spine Surg 2024; 37:178-181. [PMID: 38637927 DOI: 10.1097/bsd.0000000000001624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/10/2024] [Indexed: 04/20/2024]
Abstract
STUDY DESIGN Retrospective Review. OBJECTIVE The purpose of this study is to evaluate the efficacy of postoperative cervical orthoses to prevent fixation failure and loss of reduction after operative treatment of cervical spine fractures. SUMMARY OF BACKGROUND DATA While cervical orthoses are most times tolerated in trauma patients, it is not clear that postoperative bracing is effective at reducing the rate of fixation failure or nonunion in this patient population. Cervical collars may delay rehabilitation, increase the risk of dysphagia and aspiration, and can contribute to skin breakdown. METHODS All patients who underwent operative stabilization for cervical spine injuries at a single institution between January 2015 and August 2019 were identified through the institutional Research Electronic Data Capture (REDcap) database. Patient data, including cervical spine injury, surgery, post-operative orthosis use, and secondary surgeries for loss of reduction or infection, were recorded for all patients meeting the inclusion criteria. The primary outcome was the loss of reduction or failure of fixation, requiring revision surgery. Statistical analysis was performed using Jamovi (Version 1.1) statistical software. RESULTS In all, 201 patients meeting inclusion and exclusion criteria were identified within the study period. Overall, 133 (66.2%) patients were treated with a cervical orthosis postoperatively and 68 (33.8%) patients were allowed to mobilize as tolerated without a cervical orthosis. Fixation failure and loss of reduction occurred in 4 (1.99%) patients. Of these 4, three patients were treated with a cervical orthosis postoperatively. There was no significant difference in the risk of instrumentation failure between patients in the postoperative orthosis and no orthosis groups ( P =0.706). CONCLUSION The use of cervical orthoses after operative stabilization of cervical spine injuries remains controversial. There was no statistically significant difference in hardware failure or loss of fixation between patients treated in cervical orthoses postoperatively and those who were not.
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Affiliation(s)
| | | | - Ran Lador
- University of Texas Health Science Center
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Closs M, Brennan P, Niven A, Shenkin S, Eborall H, Lawton J. Understanding the quality-of-life experiences of older or frail adults following a new dens fracture: Nonsurgical management in a hard collar versus early removal of collar. Health Expect 2024; 27:e14017. [PMID: 38488427 PMCID: PMC10941537 DOI: 10.1111/hex.14017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 03/18/2024] Open
Abstract
INTRODUCTION In the United Kingdom, fractures of the cervical dens process in older and/or frail patients are usually managed nonsurgically in a hard collar. However, hard collars can lead to complications and this management approach is now being questioned, with growing interest in maximising patients' short-term quality-of-life. It is vital that patients' perspectives are considered; yet, there is a dearth of literature examining the aspect. To help inform wider decision-making about use of collar/no collar management of dens fractures in older/frail people, we explored older/frail people's experience of the two management approaches and how they affected their perceived quality-of-life. METHODS We interviewed older and/or frail adults with a recent dens fracture (aged ≥65 years or with a clinical frailty score of ≥5) or their caregiver. Participants were recruited from both arms of a clinical trial comparing management using a hard collar for 12 weeks (SM) with early removal of the collar (ERC) and were interviewed following randomisation and again, 12-16 weeks later. Data were analysed using a framework approach. RESULTS Both participant groups (SM/ERC) reported substantial, negative quality-of-life (QoL) experiences, with the fall itself and lack of access to care services and information being frequent major contributory factors. Many negative experiences cut across both participant groups, including pain, fatigue, diminished autonomy and reduced involvement in personally meaningful activities. However, we identified some subtle, yet discernible, ways in which using SM/ERC reinforced or alleviated (negative) QoL impacts, with the perceived benefits/burdens to using SM/ERC varying between different individuals. CONCLUSION Study findings can be used to support informed decision-making about SM/ERC management of dens fractures in older/frail patients. PATIENT OR PUBLIC CONTRIBUTION Public and patient involvement contributors were involved in the study design, development of interview topic guides and interpretation of study findings.
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Affiliation(s)
- Mia Closs
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Paul Brennan
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland
| | - Angela Niven
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Susan Shenkin
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Helen Eborall
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Julia Lawton
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland
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Hasandarras AKH, Strandvik GF, Faramawy AE, Areibi NN, Younis B, Mekkodothil A, El-Menyar A, Rizoli S, Al-Thani H. Intensive Care Physician-Led Clearance of the Cervical Spine: A Retrospective Review of the Utility of a Normal Cervical CT Scan for Safe Removal of Hard Collars by Critical Care Physicians. J Intensive Care Med 2023; 38:903-910. [PMID: 37583289 DOI: 10.1177/08850666231194529] [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: 08/17/2023]
Abstract
Background: Cervical spine clearance in intubated patients due to blunt trauma remains contentious. Accumulating evidence suggests that a normal computed tomography (CT) cervical spine can be used to clear the cervical spine and remove the collar in unconscious patients presenting to the emergency department. However, whether this strategy can safely be employed by critical care physicians with intubated patients admitted to the trauma intensive care unit (TICU) with cervical collars in situ, has not been definitively studied. Methods: A retrospective review of 730 intubated victims of trauma who presented to the Level 1 Trauma center of a tertiary hospital was conducted. The rates of missed cervical injuries in patients who had their cervical collars removed by intensive care physicians based on a normal CT scan of the cervical spine, were reviewed. Secondary outcomes included rates of collar-related complications. Results: Three hundred and fifty patients had their cervical collars removed by Trauma ICU doctors based on a high-quality, radiologist-interpreted normal CT cervical spine. Seventy percent of patients were sedated and/or comatose at the time of collar removal. Fifty-one percent of patients had concomitant traumatic brain injury. The average GCS at time of collar removal was 9. The incidence of missed neurological injury discerned clinically at time of both ICU and hospital discharge was nil (negative predictive value 100%). The rate of collar-related complications was 2%. Conclusion: Cervical collar removal by intensive care physicians on TICU following normal CT cervical spine, is safe, provided certain quality conditions related to the CT scan are met. Not removing the collar early may be associated with increased complications. An algorithm is suggested to assist critical care decision-making in this patient cohort.
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Affiliation(s)
| | | | | | | | - Basil Younis
- Trauma Surgery Department, Hamad General Hospital, HMC, Doha, Qatar
| | | | - Ayman El-Menyar
- Trauma Surgery Department, Hamad General Hospital, HMC, Doha, Qatar
| | - Sandro Rizoli
- Trauma Surgery Department, Hamad General Hospital, HMC, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Department, Hamad General Hospital, HMC, Doha, Qatar
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Brannigan JF, Dohle E, Critchley GR, Trivedi R, Laing RJ, Davies BM. Adverse Events Relating to Prolonged Hard Collar Immobilisation: A Systematic Review and Meta-Analysis. Global Spine J 2022; 12:1968-1978. [PMID: 35333123 PMCID: PMC9609519 DOI: 10.1177/21925682221087194] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To evaluate systematically the complications of prolonged cervical immobilisation in a hard collar. METHODS Following registration with PROSPERO, a systematic search of electronic databases (MEDLINE, EMBASE) was conducted. Two reviewers independently screened the search results according to pre-determined search criteria. Data was extracted and tabulated. Joanna Briggs Institute checklists were used for assessing the quality of included studies. RESULTS The search identified 773 articles. A total of 25 studies were selected for final inclusion. The results largely comprised a mixture of case reports/series, cohort studies and reviews. The most commonly reported complications were pressure ulcers, dysphagia and increased intracranial pressure. A pressure ulcer pooled prevalence of 7% was calculated. There was insufficient data for quantitative analysis of any other complication. CONCLUSIONS There is significant morbidity from prolonged hard collar immobilisation, even amongst younger patients. Whilst based upon limited and low-quality evidence, these findings, combined with the low-quality evidence for the efficacy of hard collars, highlights a knowledge gap for future research.
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Affiliation(s)
- Jamie F.M. Brannigan
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,School of Clinical Medicine, University of Cambridge, Cambridge, UK,Jamie F.M. Brannigan BA, Division of
Neurosurgery, Department of Clinical Neurosciences, University of Cambridge,
Jesus College, Cambridge CB5 8BL, UK.
| | - Esmee Dohle
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Giles R. Critchley
- Department of Neurosurgery, Brighton and Sussex University
Hospitals National Health Service Trust, Brighton, UK
| | - Rikin Trivedi
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Rodney J. Laing
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Benjamin M. Davies
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Myelopathy.org, University of Cambridge, UK
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Benchetrit S, Blackham J, Braude P, Halliday R, Shipway D, Williams A, Carlton E. Emergency management of older people with cervical spine injuries: an expert practice review. Emerg Med J 2021; 39:331-336. [PMID: 34344732 DOI: 10.1136/emermed-2020-211002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/26/2021] [Indexed: 11/03/2022]
Abstract
Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.
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Affiliation(s)
| | | | - Philip Braude
- Department of Medicine for Older People, Southmead Hospital, Bristol, UK
| | - Ruth Halliday
- Trauma & Orthopaedic Research Team, Southmead Hospital, Bristol, UK
| | - David Shipway
- Department of Medicine for Older People, Southmead Hospital, Bristol, UK
| | - Adam Williams
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
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Harris L, Arif S, Elliot M, Brady Z, Lawrence A, Lee C, Tsang K. Fusion rates for conservative and surgical management of type II odontoid fractures and its impact. Br J Neurosurg 2021; 35:607-610. [PMID: 33998359 DOI: 10.1080/02688697.2021.1926921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Type II odontoid fractures are known to have low fusion rates following conservative management with a hard collar. However, most patients are elderly with comorbidities and are not fit for surgery. The present study identified the rates of bony fusion, complications, and clinical outcomes following conservative management of type II odontoid fractures. METHODS We included consecutive patients referred with a suspected odontoid fracture to a Major Trauma Centre in the UK between March 2015 and December 2017. Data including patient demographics, fracture management, complications and outcomes. Bony fusion was assessed by two neurosurgeons and one neuroradiologists. Results were analysed with simple statistics and chi-squared test. RESULTS 102 patients were included in the study (mean age = 80.4 ± 15.3). 10 (9.8%) were managed surgically and 92 (90.2%) were managed conservatively with a hard collar, for a mean of 87 days. Patients were followed up for a mean of 28.1 months (range 1-855 days) until discharge. 37% developed collar complications, namely pain, stiffness and non-tolerance. Bony union was achieved in 37.3% of patients treated with a hard collar (versus 80% in the surgical group, p = 0.0096). Increasing age was an independent risk factor for non-union (p < 0.001). Of the patients without bony union, none reported symptoms, and 90% were discharged without a collar. CONCLUSION The management of type II odontoid fractures are difficult in an elderly, co-morbid population. With conservative management fusion rates are low, and collar complications are not insignificant. However, outcomes are good regardless of union.
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Affiliation(s)
- Lauren Harris
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | | | - Matthew Elliot
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | | | - Alistair Lawrence
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Cheong Lee
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Kevin Tsang
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
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Moran V, Pulliam T, Rodin M, Freeman C, Israel H. Cervical Injury Outcomes among Older Adults Admitted to an Inpatient Trauma Service. J Nutr Health Aging 2021; 25:392-398. [PMID: 33575733 DOI: 10.1007/s12603-021-1589-3] [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: 10/22/2022]
Abstract
OBJECTIVE Older adults are an increasing proportion of patients admitted to trauma services. Trauma in older adults' results from many mechanisms of injury with the distribution of mechanisms of injury among older adults different than those of younger adults. The acute management of these injuries may determine the patients' ability to return to independent living. It is known that prolonged immobilization of older patients results in deterioration of their functional status and increases the likelihood of hospital acquired complications, notably pneumonia, delirium, and loss of ambulation. DESIGN/SETTING We reviewed 213 patients aged 65 and older admitted to our trauma services who sustained cervical spine injuries that were either placed in c spine immobilization or were not to understand the outcomes associated with their mechanism of injury. RESULTS The youngest patients (65-74 years) were proportionately more likely to have sustained high energy injuries associated with motor vehicle crashes (36%) with a mortality rate of 11.5%. The oldest age group (> 85 years) had a higher mortality rate from falls from standing injuries (31%). Patients discharged with a collar were more likely to return to independent living. In addition, 96% of the patients that died in the acute care setting were not in cervical collar immobilization. CONCLUSION Patients under 85 years with a cervical spine injury should be placed in c-spine immobilization and aggressively managed with a multidisciplinary team approach. The older adult trauma population requires specialty care including rapid cervical spine evaluation and prescreening of functional status on admission. The NEXUS guideline should be enhanced for the older adult trauma population.
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Affiliation(s)
- V Moran
- Vicki Moran, PhD, RN, Trauma Research Coordinator, SSM Health Saint Louis University Hospital, Assistant Professor Saint Louis University, 3525 Caroline Street, St. Louis, MO 63104, 314.977.8953,
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Cubitt M, Downie E, Shakerian R, Lange PW, Cole E. Timing and methods of frailty assessments in geriatric trauma patients: A systematic review. Injury 2019; 50:1795-1808. [PMID: 31376920 DOI: 10.1016/j.injury.2019.07.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The trauma population is aging and better prognostic measures for geriatric trauma patients are required. Frailty rather than age appears to be associated with poor outcomes. This systematic review aimed to identify the optimum frailty assessment instrument and timing of assessment in patients aged over 65 years admitted to hospital after traumatic injury. The secondary aim was to evaluate outcomes associated with frailty in elderly trauma populations. METHODS This systematic review was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018090620). A MEDLINE and EMBASE literature search was conducted from inception to June 2019 combining the concepts of injury, geriatric, frailty, assessment and prognosis. Included studies were in patients 65 years or older hospitalised after injury and exposed to an instrument meeting consensus definition for frailty assessment. Study quality was assessed using criteria for review of prognostic studies combined with a GRADE approach. RESULTS Twenty-eight papers met inclusion criteria. Twenty-eight frailty or component instruments were reported, and assessments of pre-injury frailty were made up to 1-year post injury. Pre-injury frailty prevalence varied from 13% (13/100) to 94% (17/18), with in-hospital mortality rates from 2% (5/250) to 33% (6/18). Eleven studies found an association between frailty and mortality. Eleven studies reported an association between frailty and a composite outcome of mortality and adverse discharge destination. Generalisability and assessment of strength of associations was limited by single centre studies with inconsistent findings and overlapping cohorts. CONCLUSIONS Associations between frailty and adverse outcomes including mortality in geriatric trauma patients were demonstrated despite a range of frailty instruments, administering clinicians, time of assessment and data sources. Although evidence gaps remain, incorporating frailty assessment into trauma systems is likely to identify geriatric patients at risk of adverse outcomes. Consistency in frailty instruments and long-term geriatric specific outcome measures will improve research relevance. LEVEL OF EVIDENCE Level III prognostic.
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Affiliation(s)
- Mya Cubitt
- Department of Emergency Medicine, The Royal Melbourne Hospital, VIC, Australia.
| | - Emma Downie
- Trauma Service, The Royal Melbourne Hospital, VIC, Australia
| | - Rose Shakerian
- Trauma Service, The Royal Melbourne Hospital, VIC, Australia
| | - Peter W Lange
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, VIC, Australia
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, England
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Peck GE, Shipway DJH, Tsang K, Fertleman M. Cervical spine immobilisation in the elderly: a literature review. Br J Neurosurg 2018; 32:286-290. [PMID: 29488398 DOI: 10.1080/02688697.2018.1445828] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Developed populations are ageing rapidly and by 2040, approximately 1 in 4 adults will be over 65 years of age. This is resulting in higher incidence of traumatic injury in older patients. Cognitive and physical comorbidities in this group can pose significant challenges. Due to mechanisms of injury and pre-existing degenerative spinal disease, cervical spine fractures are particularly prevalent in elderly patients. These are associated with significant morbidity and mortality. In this literature review we examine current evidence surrounding the use of cervical spine immobilisation in elderly patients in the pre-hospital and emergency department setting and also as a treatment option for cervical spine fractures. We explore evidence surrounding the complications that can arise from cervical spine immobilisation, including the development of pressure sores, raised intracranial pressure, dysphagia, breathing difficulties, delirium, compliance issues, mobility and functional outcome.
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Affiliation(s)
- George Edward Peck
- a Division of Surgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
| | | | - Kevin Tsang
- c Division of Neurosurgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
| | - Michael Fertleman
- a Division of Surgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
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Risk Factors for Failure of Nonoperative Treatment for Unilateral Cervical Facet Fractures. Asian Spine J 2017; 11:356-364. [PMID: 28670403 PMCID: PMC5481590 DOI: 10.4184/asj.2017.11.3.356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 10/21/2016] [Accepted: 10/31/2016] [Indexed: 11/18/2022] Open
Abstract
Study Design Retrospective clinical study. Purpose The purpose of this study was to determine what percentage of patients who underwent nonoperative management of unilateral non-displaced or minimally displaced facet fractures progressed radiographically and to determine what percentage of patients required surgical intervention and to identify risk factors for failure of conservative management. Overview of Literature According to most commonly used classification systems, unilateral, non-and minimally displaced facet fractures are be amendable to nonoperative management. Methods A retrospective review of the Trauma Registry of a Level I trauma center was performed to identify all patients diagnosed with a non- or minimally displaced unilateral facet fracture which was managed nonoperatively. Several demographic variables and clinical outcomes were recorded. Using computed tomography scanning and plain radiographs, fracture pattern, listhesis, displacement, angle and percentage of the facet that included the fracture were determined. Radiographic progression was defined as the occurrence of listhesis of more than 10% of the anterior-posterior dimensions of the inferior vertebral body during radiographic follow-up. Failure of conservative management was defined as a patient requiring surgical intervention after initially being managed nonoperatively. Results Seventy-four patients were included. Fifteen patients (20%) progressed radiographically. However, only 2 developed radicular symptoms and none developed myelopathy or other catastrophic cord related symptoms. Seven patients (9%) underwent surgery. Indications for surgery included significant radiographic progression and/or radicular symptoms. Risk factors for failure of conservative management included presence of radiculopathy at the time of presentation, a higher body mass index, increased Injury Severity Score, greater initial fracture displacement and more than 2 mm of listhesis. Conclusions Patients with non-displaced or minimally displaced facet fractures who do not have neurological symptoms at the time of presentation can safely be managed conservatively with careful observation and follow-up.
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Abelairas-Gómez C, Barcala-Furelos R, Palacios-Aguilar J, Rodríguez-Núñez A. In-water secondary spinal cord injury prevention. Does out-of-water cervical immobilization save time? Am J Emerg Med 2016; 34:1172-4. [PMID: 27146457 DOI: 10.1016/j.ajem.2016.03.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 03/19/2016] [Indexed: 11/30/2022] Open
Affiliation(s)
- Cristian Abelairas-Gómez
- CLINURSID Research Group, Nursing Department, University of Santiago de Compostela, Santiago de Compostela, Spain; Faculty of Health Sciences, European Atlantic University, Santander, Spain.
| | - Roberto Barcala-Furelos
- CLINURSID Research Group, Nursing Department, University of Santiago de Compostela, Santiago de Compostela, Spain; Faculty of Education and Sport Sciences, University of Vigo, Pontevedra, Spain
| | - José Palacios-Aguilar
- Faculty of Sport Sciences and Physical Education, University of A Coruña, A Coruña, Spain
| | - Antonio Rodríguez-Núñez
- CLINURSID Research Group, Nursing Department, University of Santiago de Compostela, Santiago de Compostela, Spain; Pediatric Area, Pediatric Emergency and Critical Care Division, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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Kammerlander C, Zegg M, Schmid R, Gosch M, Luger TJ, Blauth M. Fragility Fractures Requiring Special Consideration. Clin Geriatr Med 2014; 30:361-72. [DOI: 10.1016/j.cger.2014.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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