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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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Occult Disco-Ligamentous Lesions of the Subaxial c-Spine-A Comparison of Preoperative Imaging Findings and Intraoperative Site Inspection. Diagnostics (Basel) 2021; 11:diagnostics11030447. [PMID: 33807826 PMCID: PMC7998602 DOI: 10.3390/diagnostics11030447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 12/14/2022] Open
Abstract
Despite the general acceptance of magnetic resonance imaging (MRI) as the gold standard for diagnostics of traumatic disco-ligamentous injuries in the subaxial cervical spine, clinical experience shows cases where no lesion is detected in MRI exams but obtained during surgery. The aim of this study was to compare intraoperative site inspection to preoperative imaging findings and to identify radiological features of patients having a risk for under- or over-estimating disco-ligamentous lesions. We performed a retrospective analysis of our clinical database, considering all patients who underwent surgical treatment of the cervical spine via an anterior approach after trauma between June 2008 and April 2018. Only patients with availability of immediate preoperative computed tomography (CT), 3-Tesla MRI scans, and information about intraoperative findings were considered. Results of preoperative imaging were set in context to intraoperative findings, and receiver operator characteristics (ROC) were calculated. Out of 144 patients receiving anterior cervical surgery after trauma, 83 patients (mean age: 59.4 ± 20.5 years, age range: 12–94 years, 63.9% males) were included in this study. Included patients underwent surgical treatment via anterior cervical discectomy and fusion (ACDF; 79 patients) or anterior cervical corpectomy and fusion (4 patients) with ventral plating. Comparing preoperative imaging findings to intraoperative site inspection, a discrepancy between imaging and surgical findings was revealed in 14 patients, leading to an overall specificity/sensitivity of preoperative imaging to identify disco-ligamentous lesions of the cervical spine of 100%/77.4%. Yet, adding the existence of prevertebral hematoma and/or vertebral fractures according to preoperative imaging improved the sensitivity to 95.2%. Lack of sensitivity was most likely related to severe cervical spondylosis, rendering correct radiological reporting difficult. Thus, the risk of missing a traumatic disco-ligamentous injury of the cervical spine in imaging seems to be a particular threat in patients with preexisting degenerative cervical spondylosis. In conclusion, incorporating the existence of prevertebral hematoma and/or vertebral fractures can significantly improve diagnostic yield.
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Häske D, Lefering R, Stock JP, Kreinest M. Epidemiology and predictors of traumatic spine injury in severely injured patients: implications for emergency procedures. Eur J Trauma Emerg Surg 2020; 48:1975-1983. [PMID: 33025171 PMCID: PMC9192373 DOI: 10.1007/s00068-020-01515-w] [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: 07/29/2020] [Accepted: 09/25/2020] [Indexed: 10/30/2022]
Abstract
PURPOSE This study aimed to identify the prevalence and predictors of spinal injuries that are suitable for immobilization. METHODS Retrospective cohort study drawing from the multi-center database of the TraumaRegister DGU®, spinal injury patients ≥ 16 years of age who scored ≥ 3 on the Abbreviated Injury Scale (AIS) between 2009 and 2016 were enrolled. RESULTS The mean age of the 145,833 patients enrolled was 52.7 ± 21.1 years. The hospital mortality rate was 13.9%, and the mean injury severity score (ISS) was 21.8 ± 11.8. Seventy percent of patients had no spine injury, 25.9% scored 2-3 on the AIS, and 4.1% scored 4-6 on the AIS. Among patients with isolated traumatic brain injury (TBI), 26.8% had spinal injuries with an AIS score of 4-6. Among patients with multi-system trauma and TBI, 44.7% had spinal injuries that scored 4-6 on the AIS. Regression analysis predicted a serious spine injury (SI; AIS 3-6) with a prevalence of 10.6% and cervical spine injury (CSI; AIS 3-6) with a prevalence of 5.1%. Blunt trauma was a predictor for SI and CSI (OR 4.066 and OR 3.640, respectively; both p < 0.001) and fall > 3 m for SI (OR 2.243; p < 0.001) but not CSI (OR 0.636; p < 0.001). Pre-hospital shock was predictive for SI and CSI (OR 1.87 and OR 2.342, respectively; both p < 0.001), and diminished or absent motor response was also predictive for SI (OR 3.171) and CSI (OR 7.462; both p < 0.001). Patients over 65 years of age were more frequently affected by CSI. CONCLUSIONS In addition to the clinical symptoms of pain, we identify '4S' [spill (fall) > 3 m, seniority (age > 65 years), seriously injured, skull/traumatic brain injury] as an indication for increased attention for CSIs or indication for spinal motion restriction.
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Affiliation(s)
- David Häske
- German Red Cross, Emergency Medical Service, Obere Wässere 1, 72764, Reutlingen, Germany. .,Center for Public Health and Health Services Research, University Hospital Tübingen, Tübingen, Germany.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Jan-Philipp Stock
- Department of Anesthesiology, Intensive Care Medicine, Emergency and Pain Medicine, Klinikum am Steinenberg, Reutlingen, Germany
| | - Michael Kreinest
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
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Henninger B, Kaser V, Ostermann S, Spicher A, Zegg M, Schmid R, Kremser C, Krappinger D. Cervical Disc and Ligamentous Injury in Hyperextension Trauma: MRI and Intraoperative Correlation. J Neuroimaging 2019; 30:104-109. [PMID: 31498526 PMCID: PMC7003840 DOI: 10.1111/jon.12663] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/30/2019] [Accepted: 08/31/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE To identify and evaluate diagnostic magnetic resonance imaging (MRI) features in patients with suspicion of discoligamentous cervical injury after hyperextension trauma of the cervical spine. METHODS MR images with a standard protocol (1.5 T, including sagittal T2‐weighted images and short tau inversion recovery [STIR]) in 21 patients without any sign of fracture or instability on multidetector computed tomography of the cervical spine were assessed. Among other structures we evaluated the following: prevertebral hematoma, anterior longitudinal ligament (ALL), intervertebral disc, and spinal cord. Presence and the anatomic level of injury were identified and recorded. Results were then compared with intraoperative findings as a reference standard. Simple descriptive statistical analysis, agreement coefficients (given by calculating the percent agreement), and the determination of Gwet's AC1 coefficient were used to analyze our results. RESULTS The overall percent agreement between STIR and intraoperative findings was 90.9% (AC1 = .881) and for T2 69.7% (AC1 = .498). For the ALL, the overall agreement was 87.9% (AC1 = .808) and for the intervertebral disc 78.8% (AC1 = .673), in which STIR always showed a higher agreement. Prevertebral hematoma was found in 20 of 21 patients with the maximum thickness at the same anatomic level as the intraoperatively proven lesion in 12 of 18 patients (67%). Edema and/or hemorrhage of the spinal cord was shown in 16 of 21 being at the same anatomic level as the intraoperatively confirmed pathology in 16 of 16 patients (100%). CONCLUSIONS MRI is a reliable tool for the evaluation of discoligamentous injuries in the cervical spine, with ancillary features proven as helpful information.
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Affiliation(s)
- Benjamin Henninger
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Kaser
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefanie Ostermann
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anna Spicher
- Department of Trauma Surgery and Sports Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Zegg
- Department of Trauma Surgery and Sports Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Rene Schmid
- Department of Trauma Surgery and Sports Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Kremser
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Krappinger
- Department of Trauma Surgery and Sports Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Izzo R, Popolizio T, Balzano RF, Pennelli AM, Simeone A, Muto M. Imaging of cervical spine traumas. Eur J Radiol 2019; 117:75-88. [DOI: 10.1016/j.ejrad.2019.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/06/2019] [Indexed: 11/28/2022]
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Deacon C, Craxford S, Ollivere BJ. Evaluating the cervical spine in confused or unconscious adults after blunt trauma. Br J Hosp Med (Lond) 2019; 80:317-319. [PMID: 31180783 DOI: 10.12968/hmed.2019.80.6.317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Potential injury to the cervical spine should be considered in all patients who have suffered blunt trauma. Early spinal immobilization is required to minimize the risk of secondary spinal cord injury. However, prolonged immobilization is associated with its own morbidity. Clinical evaluation of the cervical spine in confused or unconscious adult trauma patients is challenging, and imaging is required to safely 'clear' the cervical spine. Despite the existence of national guidelines, significant variations in practice exist. This article summarizes the evidence for the initial stabilization of the cervical spine in adult trauma patients. It reviews the imaging modalities available and the criteria for discontinuation of cervical spine immobilization.
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Affiliation(s)
- Christopher Deacon
- FY2 Doctor, Academic Orthopaedics, Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH
| | - Simon Craxford
- Research Fellow, Academic Orthopaedics, Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham
| | - Benjamin J Ollivere
- Clinical Associate Professor for Trauma, Academic Orthopaedics, Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham
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Abstract
STUDY DESIGN This was a prospective simulator study with 16 healthy male subjects. OBJECTIVE The aim of this study was to compare the relative efficacy of immobilization systems in limiting involuntary movements of the cervical spine using a dynamic simulation model. SUMMARY OF BACKGROUND DATA Relatively few studies have tested the efficacy of immobilization methods for limiting involuntary cervical movement, and only one of these studies used a dynamic simulation system to do so. METHODS Immobilization configurations tested were cot alone, cot with cervical collar, long spine board (LSB) with cervical collar and head blocks, and vacuum mattress (VM) with cervical collar. A motion platform reproduced shocks and vibrations from ambulance and helicopter field rides, as well as more severe shocks and vibrations that might be encountered on rougher terrain and in inclement weather (designated as an "augmented" ride). Motion capture technology quantitated involuntary cervical rotation, flexion/extension, and lateral bend. The mean and 95% confidence interval of the mean were calculated for the root mean square of angular changes from the starting position and for the maximum range of motion. RESULTS All configurations tested decreased cervical rotation and flexion/extension relative to the cot alone. However, the LSB and VM were significantly more effective in decreasing cervical rotation than the cervical collar, and the LSB decreased rotation more than the VM in augmented rides. The LSB and VM, but not the cervical collar, significantly limited cervical lateral bend relative to the cot alone. CONCLUSION Under the study conditions, the LSB and the VM were more effective in limiting cervical movement than the cervical collar. Under some conditions, the LSB decreased repetitive and acute movements more than the VM. Further studies using simulation and other approaches will be essential for determining the safest, most effective configuration should providers choose to immobilize patients with suspected spinal injuries. LEVEL OF EVIDENCE 3.
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Veiga JRS, Mitchell K. Cervical spine clearance in the adult obtunded blunt trauma patient: A systematic review. Intensive Crit Care Nurs 2018; 51:57-63. [PMID: 30509691 DOI: 10.1016/j.iccn.2018.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 10/02/2018] [Accepted: 11/05/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND A missed cervical spinal injury could have devastating consequences. Patients with a suspected cervical spinal injury are kept in rigid collars for cervical immobilisation. Prolonged collar use has important clinical implications. A well-defined guideline related to the removal of cervical collars from adult obtunded blunt trauma patients has not been developed. AIM We sought to determine if Magnetic Resonance Imaging offered a definitive benefit over Computer Tomography with respect to patient management. METHOD We searched Ovid Online, EBSCO, NICE Evidence Journals, Medline, PubMED, BNI, CINAHL and Google Scholar as well as the grey literature. Data extraction and synthesis were performed on studies that compared the radiologic findings and clinical outcomes of Computer Tomography scan and Magnetic Resonance Imaging in this patient group. RESULTS There is evidence that supports the safe discontinuation of cervical collar use after a negative multidetector Computer Tomography scan result alone. Magnetic Resonance Imaging may detect a significant number of ligamentous injuries, but such injuries are rarely of clinical significance because they rarely alter clinical management. Its use should be limited to specific circumstances. CONCLUSION It is important for institutions to re-examine the latest evidence regarding cervical spinal clearance in order to update their guidelines.
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Affiliation(s)
| | - Kay Mitchell
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton, Southampton, UK
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Abstract
Instability of the spine is a complex clinical entity that exists on a wide spectrum encompassing many aspects of spinal pathology including traumatic, neoplastic, infectious, and degenerative processes. The importance of determining stability is paramount in the decision-making process regarding the need for operative or nonoperative care. Defining clinical instability can be a challenging and requires careful attention to the pathology involved, findings of necessary imaging, and a thorough clinical exam. Several classification systems have been developed to aid in surgical decision making, but certain limitations exist. Various imaging modalities play a crucial role in the evaluation of suspected instability. Computed tomography is the initial imaging modality of choice in the traumatic setting. Magnetic resonance imaging is an important adjunct in the setting of suspected ligamentous injury and the modality of choice in suspected infectious and neoplastic processes. Upright radiographs can be particularly useful in the setting of acute or subacute instability to glean information about how the spine responds to gravity and weightbearing. The clinical exam is also of critical importance in the determination of stability. The presence of a neurologic deficit is highly suggestive of a potentially unstable spine and appropriate spinal precautions should be maintained until instability and injury has been ruled out. Certain clinical entities, such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, are at high risk for instability particularly in the traumatic setting. In these situations, the spine should be considered unstable until proven otherwise. Ultimately, the determination of spinal stability, and subsequent need for surgical treatment, should be based on the individual case. Combining information from the clinical exam and imaging findings, including upright radiographs when appropriate, allows for the appropriated determination of spinal stability.
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Affiliation(s)
- Scott A Vincent
- Department of Orthopedic Surgery & Rehabilitation, University of Nebraska Medical Center, Omaha, NE.
| | - Paul A Anderson
- Department of Orthopedic Surgery & Rehabilitation, University of Nebraska Medical Center, Omaha, NE
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Prevalence of concomitant traumatic cranio-spinal injury: a systematic review and meta-analysis. Neurosurg Rev 2018; 43:69-77. [PMID: 29882173 PMCID: PMC7010651 DOI: 10.1007/s10143-018-0988-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/12/2018] [Accepted: 05/28/2018] [Indexed: 10/28/2022]
Abstract
The biomechanical relationship between cranial and spinal structures makes concomitant injury likely. Concomitant cranio-spinal injuries are important to consider following trauma due to the serious consequences of a missed injury. The objective of this review was to estimate the prevalence of concomitant cranio-spinal injury in the adult trauma population. A systematic search of MEDLINE and EMBASE databases to identify observational studies reporting the prevalence of concomitant cranio-spinal injury in the general adult trauma population was conducted on 21 March 2017. The prevalence of concomitant cervical spinal injury in patients with a traumatic brain injury (TBI); the prevalence of concomitant spinal injury in patients with a TBI; the prevalence of concomitant TBI in patients with a cervical spinal injury; and the prevalence of concomitant TBI in patients with a spinal injury were calculated by meta-analysis. Twenty-one studies met the inclusion criteria and were included in this review. The prevalence of concomitant cervical spinal injury in patients with a TBI was found to be 6.5% (95% CI 6.0-7.1%); the prevalence of concomitant spinal injury in patients with a TBI to be 12.4-12.5%; the prevalence of concomitant TBI in patients with a cervical spinal injury to be 40.4% (95% CI 33.0-48.0%); and the prevalence of concomitant TBI in patients with a spinal injury to be 32.5% (95% CI 10.8-59.3%). This review reports the prevalence of concomitant cranio-spinal injury and highlights the importance of considering concomitant injury in patients with a cranial or spinal traumatic injury.
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Magnetic Resonance Imaging of Trauma Patients Treated With Contemporary External Fixation Devices: A Multicenter Case Series. J Orthop Trauma 2017; 31:e375-e380. [PMID: 28827510 DOI: 10.1097/bot.0000000000000954] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To report the safety and clinical outcomes of placing current magnetic resonance imaging (MRI) components inside and outside the MRI bore during MRIs. DESIGN Retrospective case series. SETTING Four trauma centers (3 Level I and 1 Level II), from January 2005 to January 2015. PATIENTS All patients who had MRIs with external fixators in place either inside or outside the MRI bore. INTERVENTION MRI of patients with external fixator in place. MAIN OUTCOME MEASUREMENTS Adverse events were defined as catastrophic pullout of the external fixator during the MRI, thermal injury to the skin, severe field distortions precluding the intended imaging, alterations of the magnetic field, or visible structural damage to the magnet casing. RESULTS Thirty-eight patients with 44 external fixators were identified who had MRI with the fixator inside or outside the MRI bore. Twelve patients with 13 external fixators had MRI with the external fixator inside the MRI bore. Twenty-seven patients with 32 external fixators had MRI with the external fixator outside the MRI bore. There were no adverse events. CONCLUSIONS Although no universal guidelines exist, there are circumstances in which obtaining MRIs of patients with external fixators can be safe. This is the first clinical series with the primary outcome of safety when placing modern external components both inside and outside an MRI bore during a scan. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Lau BPH, Hey HWD, Lau ETC, Nee PY, Tan KA, Tan WT. The utility of magnetic resonance imaging in addition to computed tomography scans in the evaluation of cervical spine injuries: a study of obtunded blunt trauma patients. 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 2017; 27:1028-1033. [PMID: 28993912 DOI: 10.1007/s00586-017-5317-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 08/03/2017] [Accepted: 09/26/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Bernard Puang Huh Lau
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore
| | - Hwee Weng Dennis Hey
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore.
| | - Eugene Tze-Chun Lau
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore
| | - Pei Yi Nee
- Division of Family Medicine, National University Hospital, Singapore, Singapore
| | - Kimberly-Anne Tan
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore
| | - Wah Tze Tan
- Department of Anaesthesia, Ng Teng Fong General Hospital, Singapore, Singapore
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Kim M, Lee S, Song Y. Paraspinal Fat Pad Changes as a Valuable Indicator of Posterior Ligamentous Complex Injury in Upper Cervical Spine Trauma. Radiology 2017. [DOI: 10.1148/radiol.2017170268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Miso Kim
- Department of Radiology, Hanyang University Hospital, 17 Haengdang-dong, Sungdong-gu, Seoul 133-792, Korea
| | - Seunghun Lee
- Department of Radiology, Hanyang University Hospital, 17 Haengdang-dong, Sungdong-gu, Seoul 133-792, Korea
| | - Yoonah Song
- Department of Radiology, Hanyang University Hospital, 17 Haengdang-dong, Sungdong-gu, Seoul 133-792, Korea
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Cost-effectiveness of cervical spine clearance interventions with litigation and long-term-care implications in obtunded adult patients following blunt injury. J Trauma Acute Care Surg 2017; 81:897-904. [PMID: 27602907 DOI: 10.1097/ta.0000000000001243] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent guidelines from the Eastern Association for the Surgery of Trauma conditionally recommend cervical collar removal after a negative cervical computed tomography in obtunded adult blunt trauma patients. Although the rates of missed injury are extremely low, the impact of chronic care costs and litigation upon decision making remains unclear. We hypothesize that the cost-effectiveness of strategies that include additional imaging may contradict current guidelines. METHODS A cost-effectiveness analysis was performed for a base-case 40-year-old, obtunded man with a negative computed tomography. Strategies compared included adjunct imaging with cervical magnetic resonance imaging (MRI), collar maintenance for 6 weeks, or removal. Data on the probability for long-term collar complications, spine injury, imaging costs, complications associated with MRI, acute and chronic care, and litigation were obtained from published and Medicare data. Outcomes were expressed as 2014 US dollars and quality-adjusted life-years. RESULTS Collar removal was more effective and less costly than collar use or MRI (19.99 vs. 19.35 vs. 18.70 quality-adjusted life-years; $675,359 vs. $685,546 vs. $685,848) in the base-case analysis. When the probability of missed cervical injury was greater than 0.04 adjunct imaging with MRI dominated, however, collar removal remained cost-effective until the probability of missed injury exceeded 0.113 at which point collar removal exceeded the $50,000 threshold. Collar removal remained the most cost-effective approach until the probability of complications from collar use was reduced to less than 0.009, at which point collar maintenance became the most cost-effective strategy. Early collar removal dominates all strategies until the risk of complications from MRI positioning is reduced to 0.03 and remained cost-effective even when the probability of complication was reduced to 0. CONCLUSION Early collar removal in obtunded adult blunt trauma patients appears to be the most effective and least costly strategy for cervical clearance based on the current literature available. LEVEL OF EVIDENCE Economic evaluation, level III; therapeutic study, level IV.
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Molière S, Zaragori-Benedetti C, Ehlinger M, Le Minor JM, Kremer S, Bierry G. Evaluation of Paraspinal Fat Pad as an Indicator of Posterior Ligamentous Complex Injury in Cervical Spine Trauma. Radiology 2017; 282:790-797. [DOI: 10.1148/radiol.2016160330] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sébastien Molière
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Cyril Zaragori-Benedetti
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Matthieu Ehlinger
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Jean-Marie Le Minor
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Stéphane Kremer
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
| | - Guillaume Bierry
- From the Departments of Radiology (S.M., C.Z.B., J.M.L.M., S.K., G.B.) and Orthopedic Surgery (M.E.), University Hospital of Strasbourg, 10 avenue Molière, F-67098 Strasbourg, France; and ICube Laboratory (M.E., J.M.L.M., S.K., G.B.) and Institute of Anatomy (J.M.L.M.), University of Strasbourg, Strasbourg, France
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Craxford S, Bayley E, Walsh M, Clamp J, Boszczyk BM, Stokes OM. Missed cervical spine injuries: a national survey of the practice of evaluation of the cervical spine in confused and comatose patients. Bone Joint J 2017; 98-B:825-8. [PMID: 27235527 DOI: 10.1302/0301-620x.98b6.37435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 01/10/2016] [Indexed: 12/11/2022]
Abstract
AIM Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals. PATIENTS AND METHODS All hospitals in England with an Emergency Department were asked about the protocols which they use for assessing the cervical spine. All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded (response rate 91.5%). RESULTS Written guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries. TAKE HOME MESSAGE There are significant variations in protocols and practices for the clearance of the cervical spine in multiply injured patients in acute hospitals in England. The establishment of trauma networks should be taken as an opportunity to further standardise trauma care. Cite this article: Bone Joint J 2016;98-B:825-8.
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Affiliation(s)
- S Craxford
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - E Bayley
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - M Walsh
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - J Clamp
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - B M Boszczyk
- Nottingham University Hospitals, Derby Road, Nottingham NG7 2UH, UK
| | - O M Stokes
- Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK
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17
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Oh JJ, Asha SE, Curtis K. Diagnostic accuracy of flexion-extension radiography for the detection of ligamentous cervical spine injury following a normal cervical spine computed tomography. Emerg Med Australas 2016; 28:450-5. [DOI: 10.1111/1742-6723.12612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/17/2016] [Accepted: 03/14/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Jason Jaeseong Oh
- St George Clinical School, Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
| | - Stephen Edward Asha
- St George Clinical School, Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
- Emergency Department; St George Hospital; Sydney New South Wales Australia
| | - Kate Curtis
- St George Clinical School, Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
- Trauma Service; St George Hospital; Sydney New South Wales Australia
- Sydney Nursing School; The University of Sydney; Sydney New South Wales Australia
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18
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O'Sullivan MD, Piggot R, Jaddan M, McCabe JP. A game of two discs: a case of non-contiguous and occult cervical spine injury in a rugby player. J Surg Case Rep 2016; 2016:rjw031. [PMID: 26980714 PMCID: PMC4791685 DOI: 10.1093/jscr/rjw031] [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] [Indexed: 11/19/2022] Open
Abstract
The aim of this case report was to highlight the application of magnetic resonance imaging (MRI) in elucidating serious and occult injuries in a single case of hyperflextion injury of a patient cervical spine (C-Spine). A chart and radiology review was performed to establish the sequence of care and how the results of imaging studies influenced the clinical management in this trauma case. Plain radiographs and computed tomography (CT) imaging modalities of the C-Spine revealed bilateral C4/C5 facetal subluxation with no obvious fractures; however, the MR imaging of the C-Spine revealed a non-contiguous and occult injury to C6/C7 disc with a posterior annular tear and associated disc extrusion. This altered the operative intervention that was initially planned. MR imaging proved an invaluable diagnostic addition in this particular case of cervical trauma in a rugby player following a hyperflextion injury, by revealing a serious non-contiguous and occult injury of the C-Spine.
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Affiliation(s)
| | - Robert Piggot
- Galway University Hospitals (GUH), Newcastle, Galway, Republic of Ireland
| | - Mutaz Jaddan
- Galway University Hospitals (GUH), Newcastle, Galway, Republic of Ireland
| | - John P McCabe
- Galway University Hospitals (GUH), Newcastle, Galway, Republic of Ireland
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19
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Cervical spine evaluation in the bluntly injured patient. Int J Surg 2016; 33:246-250. [PMID: 26827890 DOI: 10.1016/j.ijsu.2016.01.086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 12/29/2015] [Accepted: 01/24/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cervical spine injuries causing spinal cord trauma are rare in blunt trauma yet lead to devastating morbidity and mortality when they occur. There exists considerable debate in the literature about the best way for clinicians to proceed in ruling out cervical spine injuries in alert or obtunded blunt trauma patients. METHODS We reviewed the current literature and practice management guidelines to generate clinical recommendations for the detection and clearance of cervical spine injuries in the blunt trauma patient. RESULTS The NEXUS and Canadian C-Spine Rules are clinical tools to guide in the clearance of the cervical spine of patients who have sustained low risk trauma and who are pain free, with the Canadian C-Spine Rules having superior sensitivity and specificity. In the alert, high risk patient with pain (or without, if over the age of 65 years), follow up imaging is required. The best imaging modality to use is Computerized Tomography (CT) of the cervical spine. In the obtunded trauma patient, CT clearance of c-spine injury is adequate, unless there is soft tissue injury or any non-bony abnormalities detected. At such point, definitive clearance may be obtained with Magnetic Resonance Imaging (MRI). CONCLUSIONS It is imperative to assume cervical spine injury in the blunt trauma patient. Clinical decision rules for cervical clearance may be used in low risk patients, avoiding imaging. High risk patients require imaging in the form of CT scan of the cervical spine.
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20
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Oh JJ, Asha SE. Utility of flexion-extension radiography for the detection of ligamentous cervical spine injury and its current role in the clearance of the cervical spine. Emerg Med Australas 2015; 28:216-23. [DOI: 10.1111/1742-6723.12525] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 09/22/2015] [Accepted: 10/27/2015] [Indexed: 01/26/2023]
Affiliation(s)
- Jason Jaeseong Oh
- St George Clinical School, Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
| | - Stephen Edward Asha
- St George Clinical School, Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
- Emergency Department; St George Hospital; Sydney New South Wales Australia
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21
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Young AJ, Wolfe L, Tinkoff G, Duane TM. Assessing Incidence and Risk Factors of Cervical Spine Injury in Blunt Trauma Patients Using the National Trauma Data Bank. Am Surg 2015. [DOI: 10.1177/000313481508100921] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the potentially devastating impact of missed cervical spine injuries (CI), there continues to be a large disparity in how institutions attempt to make the diagnosis. To better streamline the approach among institutions, understanding incidence and risk factors across the country is paramount. We evaluated the incidence and risk factors of CI using the National Trauma Databank for 2008 and 2009. We performed a retrospective review of the National Trauma Databank for 2008 and 2009 comparing patients with and without CI. We then performed subset analysis separating injury by patients with and without fracture and ligamentous injury. There were a total of 591,138 patients included with a 6.2 per cent incidence of CI. Regression found that age, Injury Severity Score, alcohol intoxication, and specific mechanisms of motor vehicle crash (MVC), motorcycle crash (MCC), fall, pedestrian stuck, and bicycle were independent risk factors for overall injury ( P < 0.0001). Patients with CI had longer intensive care unit (8.5 12.5 vs 5.1 7.7) and hospital lengths of stay (days) (9.6 14.2 vs 5.3 8.1) and higher mortality (1.2 per cent vs 0.3%), compared with those without injury ( P < 0.0001). There were 33,276 patient with only fractures for an incidence of 5.6 per cent and 1875 patients with ligamentous injury. Just over 6 per cent of patients suffer some form of CI after blunt trauma with the majority being fractures. Higher Injury Severity Score and MVC were consistent risk factors in both groups. This information will assist in devising an algorithm for clearance that can be used nationally allowing for more consistency among trauma providers.
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Affiliation(s)
- Andrew J. Young
- Virginia Commonwealth University Health System, Richmond, Virginia
| | - Luke Wolfe
- Christiana Care Health System, Newark, Delaware; and
| | - Glenn Tinkoff
- Christiana Care Health System, Newark, Delaware; and
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22
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Agrawal D, Sinha TP, Bhoi S. Assessment of ultrasound as a diagnostic modality for detecting potentially unstable cervical spine fractures in pediatric severe traumatic brain injury: A feasibility study. J Pediatr Neurosci 2015; 10:119-22. [PMID: 26167212 PMCID: PMC4489052 DOI: 10.4103/1817-1745.159196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Early cervical spine clearance is extremely important in unconscious trauma patients and may be difficult to achieve in emergency setting. Objectives: The aim of this study was to assess the feasibility of standard portable ultrasound in detecting potentially unstable cervical spine injuries in severe traumatic brain injured (TBI) patients during initial resuscitation. Materials and Methods: This retro-prospective pilot study carried out over 1-month period (June–July 2013) after approval from the institutional ethics committee. Initially, the technique of cervical ultrasound was standardized by the authors and tested on ten admitted patients of cervical spine injury. To assess feasibility in the emergency setting, three hemodynamically stable pediatric patients (≦18 years) with isolated severe head injury (Glasgow coma scale ≤8) coming to emergency department underwent an ultrasound examination. Results: The best window for the cervical spine was through the anterior triangle using the linear array probe (6–13 MHz). In the ten patients with documented cervical spine injury, bilateral facet dislocation at C5–C6 was seen in 4 patients and at C6–C7 was seen in 3 patients. C5 burst fracture was present in one and cervical vertebra (C2) anterolisthesis was seen in one patient. Cervical ultrasound could easily detect fracture lines, canal compromise and ligamental injury in all cases. Ultrasound examination of the cervical spine was possible in the emergency setting, even in unstable patients and could be done without moving the neck. Conclusions: Cervical ultrasound may be a useful tool for detecting potentially unstable cervical spine injury in TBI patients, especially those who are hemodynamically unstable.
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Affiliation(s)
- Deepak Agrawal
- Department of Neurosurgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Tej Prakash Sinha
- Department of Emergency Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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23
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Shrier I, Boissy P, Lebel K, Boulay J, Segal E, Delaney JS, Vacon LC, Steele RJ. Cervical Spine Motion during Transfer and Stabilization Techniques. PREHOSP EMERG CARE 2014; 19:116-125. [PMID: 25076192 DOI: 10.3109/10903127.2014.936634] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Objectives. To compare paramedics' ability to minimize cervical spine motion during patient transfer onto a vacuum mattress with two stabilization techniques (head squeeze vs. trap squeeze) and two transfer methods (log roll with one assistant (LR2) vs. 3 assistants (LR4)). Methods. We used a crossover design to minimize bias. Each lead paramedic performed 10 LR2 transfers and 10 LR4 transfers. For each of the 10 LR2 and 10 LR4 transfers, the lead paramedic stabilized the cervical spine using the head squeeze technique five times and the trap squeeze technique five times. We randomized the order of the stabilization techniques and LR2/LR4 across lead paramedics to avoid a practice or fatigue effect with repeated trials. We measured relative cervical spine motion between the head and trunk using inertial measurement units placed on the forehead and sternum. Results. On average, total motion was 3.9° less with three assistants compared to one assistant (p = 0.0002), and 2.8° less with the trap squeeze compared to the head squeeze (p = 0.002). There was no interaction between the transfer method and stabilization technique. When examining specific motions in the six directions, the trap squeeze generally produced less lateral flexion and rotation motion but allowed more extension. Examining within paramedic differences, some paramedics were clearly more proficient with the trap squeeze technique and others were clearly more proficient with the head squeeze technique. Conclusion. Paramedics performing a log roll with three assistants created less motion compared to a log roll with only one assistant, and using the trap squeeze stabilization technique resulted in less motion than the head squeeze technique but the clinical relevance of the magnitude remains unclear. However, large individual differences suggest future paramedic training should incorporate both best evidence practice as well as recognition that there may be individual differences between paramedics.
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24
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Debernardi A, Sala E, D'Aliberti G, Talamonti G, Cenzato M. Acute traumatic fractures to the craniovertebral junction: preliminary experience with the "MILD" score scale. Eur J Trauma Emerg Surg 2014; 40:343-50. [PMID: 26816070 DOI: 10.1007/s00068-014-0387-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 02/13/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Traumatic fractures to the craniovertebral junction (CVJ) are rare events requiring complex clinical management. Several classification systems are currently in use; however, recent improvements of junctional knowledge has focused attention on the role of ligaments and membranes in vertebral biomechanical stability. The aim of this study was to present our preliminary experience with the "MILD" score scale, which should allow fast and effective classification of all CVJ traumatic fractures based on vertebral instability in the acute setting. METHODS A prospective study was conducted on 38 consecutive patients with 43 traumatic junctional fractures identified by computed tomography (CT) scan in the acute trauma phase. The MILD scale was applied to all fractures, and a score was obtained for each patient. All cases underwent magnetic resonance imaging (MRI) to assess the anatomical integrity of ligaments and membranes. RESULTS Twenty-seven patients (71 %) were classified as MILD type 1 (0-1 points), showed a negative MRI, and healed with conservative treatment. Eight patients (21 %) were classified as MILD type 2 (2 points) and showed modest indirect signs of ligamentous injuries. Four of these patients healed with conservative treatment, while three patients underwent surgery due to wide bone fracture fragment displacement. Three patients (8 %) were classified as MILD type 3 (3 points), all of whom showed extensive ligamentous damage and underwent surgery. CONCLUSIONS The close association between the MILD scale and spinal instability is promising, although further studies are warranted in order to confirm our preliminary data.
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Affiliation(s)
- A Debernardi
- Department of Neurosurgery, Ospedale Niguarda Cà Granda, P.zza Ospedale Maggiore, 3, 20162, Milan, Italy.
| | - E Sala
- Department of Nursing Education, San Paolo Hospital, Milan, Italy
| | - G D'Aliberti
- Department of Neurosurgery, Ospedale Niguarda Cà Granda, P.zza Ospedale Maggiore, 3, 20162, Milan, Italy
| | - G Talamonti
- Department of Neurosurgery, Ospedale Niguarda Cà Granda, P.zza Ospedale Maggiore, 3, 20162, Milan, Italy
| | - M Cenzato
- Department of Neurosurgery, Ospedale Niguarda Cà Granda, P.zza Ospedale Maggiore, 3, 20162, Milan, Italy
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25
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Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma 2014; 31:531-40. [PMID: 23962031 PMCID: PMC3949434 DOI: 10.1089/neu.2013.3094] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.
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Affiliation(s)
- Terje Sundstrøm
- 1 Department of Biomedicine, University of Bergen , Bergen, Norway
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26
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Aarabi B, Walters BC, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Ryken TC, Theodore N, Hadley MN. Subaxial cervical spine injury classification systems. Neurosurgery 2013; 72 Suppl 2:170-86. [PMID: 23417189 DOI: 10.1227/neu.0b013e31828341c5] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
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27
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Debernardi A, D'Aliberti G, Talamonti G, Villa F, Piparo M, Ligarotti G, Cenzato M. Traumatic injuries to the craniovertebral junction: a review of rare events. Neurosurg Rev 2013; 37:203-16; discussion 216. [PMID: 23928657 DOI: 10.1007/s10143-013-0492-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 01/25/2013] [Accepted: 03/10/2013] [Indexed: 01/08/2023]
Abstract
The craniovertebral junction is a specific region of the spine with unique anatomical and biomechanical properties that yields a wide variety of injury patterns. Junctional traumatic fractures and/or dislocations are widely reported in clinical practice, but we could identify only a subgroup of upper cervical spine traumatic injuries with very few cases reported in the literature, and for this reason may be considered rare. In some of these cases, the absence of spinal biomechanical instability, in association with moderate clinical symptoms (neck stiffness and pain) and the difficulty in fracture identification through standard cervical radiographs, leads to a high percentage of missed injuries. In other cases, traumatic events have been commonly described only in autopsy series due to the high degree of spinal biomechanical instability. Herein, we have summarized all the relevant literature concerning this issue and also included our cases, with the aim of emphasizing prompt diagnosis and correct management. We provide a guide for correctly identifying "rare" craniovertebral junction traumatic injuries.
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Affiliation(s)
- Alberto Debernardi
- Department of Neurosurgery, Niguarda Cà Granda Hospital, P.zza Ospedale Maggiore, 3, 20162, Milan, Italy,
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28
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BARRON DA, MENON N. Axial trauma. IMAGING 2013. [DOI: 10.1259/imaging/63842733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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29
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Debernardi A, D'Aliberti G, Talamonti G, Villa F, Piparo M, Cenzato M. Traumatic (Type II) Odontoid Fracture with Transverse Atlantal Ligament Injury: A Controversial Event. World Neurosurg 2013; 79:779-83. [PMID: 22381856 DOI: 10.1016/j.wneu.2012.01.055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 11/21/2011] [Accepted: 11/27/2012] [Indexed: 12/13/2022]
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30
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Sierink JC, van Lieshout WAM, Beenen LFM, Schep NWL, Vandertop WP, Goslings JC. Systematic review of flexion/extension radiography of the cervical spine in trauma patients. Eur J Radiol 2013; 82:974-81. [PMID: 23489979 DOI: 10.1016/j.ejrad.2013.02.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 02/08/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The aim of this review was to investigate whether Flexion/Extension (F/E) radiography adds diagnostic value to CT or MRI in the detection of cervical spine ligamentous injury and/or clinically significant cervical spine instability of blunt trauma patients. METHODS A systematic search of literature was done in Pubmed, Embase and Cochrane Library databases. Primary outcome was sensitivity and specificity of F/E radiography. Secondary outcomes were the positive predicting value (PPV) and negative predicting value (NPV) (with CT or MRI as reference tests due to the heterogeneity of the included studies) of each modality and the quality of F/E radiography. RESULTS F/E radiography was overall regarded to be inferior to CT or MRI in the detection of ligamentous injury. This was reflected by the high specificity and NPV for CT with F/E as reference test (ranging from 97 to 100% and 99 to 100% respectively) and the ambiguous results for F/E radiography with MRI as its reference test (0-98% and 0-83% for specificity and NPV respectively). Image quality of F/E radiography was reported to have 31 to 70% adequacy, except in two studies which reported an adequacy of respectively 4 and 97%. CONCLUSION This systematic review of the literature shows that F/E radiography adds little diagnostic value to the evaluation of blunt trauma patients compared to CT and MRI, especially in those cases where CT or MRI show no indication of ligamentous injury.
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Affiliation(s)
- J C Sierink
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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31
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Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients. 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 2013; 22:1467-73. [PMID: 23404352 DOI: 10.1007/s00586-012-2598-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 10/31/2012] [Accepted: 11/15/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Flexion and extension radiographs are often used in the setting of trauma to clear a cervical spine injury. The utility of such tests, however, remains to be determined. We hypothesized that in patients who underwent a negative computed tomography (CT) cervical spine scan, flexion and extension radiographs did not yield useful additional information. METHODS We conducted a retrospective chart review of all patients admitted to a Level I trauma center who had a negative CT scan of the cervical spine and a subsequent cervical flexion-extension study for evaluation of potential cervical spine injury. All flexion-extension films were independently reviewed to determine adequacy as defined by C7/T1 visualization and 30° of change in the angle from flexion to extension. The independent reviews were compared to formal radiology readings and the influence of the flexion-extension studies on clinical decision making was also reviewed. RESULTS One thousand patients met inclusion criteria for the study. Review of the flexion-extension radiographs revealed that 80% of the films either did not adequately demonstrate the C7/T1 junction or had less than 30° range of motion. There was one missed injury that was also missed on magnetic resonance imaging. Results of the flexion-extension views had minimal effects on clinical decision making. CONCLUSION Adequate flexion extension films are difficult to obtain and are minimally helpful for clearance of the cervical spine in awake and alert trauma patients.
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Abstract
Trauma of the cervical spine is one of the most harrowing injuries seen in athletics. Although such injuries are not common, their impact can be devastating. Based on a thorough review of the literature, this article explains the identification of cervical spine trauma and the importance of stability therein. Multiple examples are given highlighting these findings and the way that multiple modalities can be used to asses such injuries. The article concludes with a brief review of the current recommendations as they relate to imaging in the initial assessment of cervical spine trauma.
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33
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Scott TE, Coates PJB, Davies SR, Gay DAT. Clearing the Spine in the Unconscious Trauma Patient: An Update. J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Clearing the spine of the unconscious traumatised patient is a task that the intensive care clinician faces frequently. Technological advances in cross-sectional imaging are such that the cervical and thoraco-lumbar spine can now be cleared quickly and reliably in a single computerised tomography imaging session, which all trauma patients require, with no extra exposure to radiation. This results in less patient manipulation and should reduce the time to cessation of unnecessary spinal precautions which themselves can lead to patient harm. Such head-to-toe inclusive ‘traumagrams’ are the standard of care received by casualties presenting at western military medical facilities in Afghanistan.
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Affiliation(s)
- Timothy E Scott
- Consultant in Anaesthetics and Intensive Care, Defence Medical Services and Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford
| | - Philip J B Coates
- Consultant Radiologist, Defence Medical Services and Plymouth Hospitals NHS Trust
| | - Sian R Davies
- Specialist Registrar, Department of Anaesthetics and Intensive Care, Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus
| | - David A T Gay
- Consultant Neuroradiologist, Defence Medical Services and Plymouth Hospitals NHS Trust, Plymouth
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Talving P, Pålstedt J, Riddez L. Prehospital Management and Fluid Resuscitation in Hypotensive Trauma Patients Admitted to Karolinska University Hospital in Stockholm. Prehosp Disaster Med 2012; 20:228-34. [PMID: 16128470 DOI: 10.1017/s1049023x00002582] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroduction:Few previous studies have been conducted on the prehospital management of hypotensive trauma patients in Stockholm County. The aim of this study was to describe the prehospital management of hypotensive trauma patients admitted to the largest trauma center in Sweden, and to assess whether prehospital trauma life support (PHTLS) guidelines have been implemented regarding prehospital time intervals and fluid therapy. In addition, the effects of the age, type of injury, injury severity, prehospital time interval, blood pressure, and fluid therapy on outcome were investigated.Methods:This is a retrospective, descriptive study on consecutive, hypotensivetrauma patients (systolic blood pressure ≤90 mmHg on the scene of injury) admitted to Karolinska University Hospital in Stockholm, Sweden, during 2001–2003. The reported values are medians with interquartile ranges. Basic demographics, prehospital time intervals and interventions, injury severity scores (ISS), type and volumes of prehospital fluid resuscitation, and 30-day mortality were abstracted. The effects of the patient's age, gender, prehospital time interval, type of injury, injury severity, on-scene and emergency department blood pressure, and resuscitation fluid volumes on mortality were analyzed using the exact logistic regression model.Results:In 102 (71 male) adult patients (age ≥15 years) recruited, the median age was 35.5 years (range: 27–55 years) and 77 patients (75%) had suffered blunt injury. The predominant trauma mechanisms were falls between levels (24%) and motor vehicle crashes (22%) with an ISS of 28.5 (range: 16–50). The on-scene time interval was 19 minutes (range: 12–24 minutes). Fluid therapy was initiated at the scene of injury in the majority of patients (73%) regardless of the type of injury (77 blunt [75%] / 25 penetrating [25%]) or injury severity (ISS: 0–20; 21–40; 41–75). Age (odds ratio (OR) = 1.04), male gender (OR = 3.2), ISS 21–40 (OR = 13.6), and ISS >40 (OR = 43.6) were the significant factors affecting outcome in the exact logistic regression analysis.Conclusion:The time interval at the scene of injury exceeded PHTLS guidelines. The vast majority of the hypotensive trauma patients were fluid-resuscitated on-scene regardless of the type, mechanism, or severity of injury. A predefined fluid resuscitation regimen is not employed in hypotensive trauma victims with different types of injuries. The outcome was worsened by male gender, progressive age, and ISS >20 in the exact multiple regression analysis.
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Affiliation(s)
- Peep Talving
- Karolinska Trauma Center, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
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Okuda T, Shiotani S, Hayakawa H, Kikuchi K, Kobayashi T, Ohno Y. A case of fatal cervical discoligamentous hyperextension injury without fracture: correlation of postmortem imaging and autopsy findings. Forensic Sci Int 2012; 225:71-4. [PMID: 22648056 DOI: 10.1016/j.forsciint.2012.04.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 04/05/2012] [Accepted: 04/30/2012] [Indexed: 10/28/2022]
Abstract
We present a case of fatal cervical discoligamentous hyperextension injury without fracture. Postmortem computed tomography (PMCT) and postmortem magnetic resonance imaging (PMMRI) disclosed cervical instability and spinal cord injury in the absence of fracture, which was confirmed by autopsy. Cervical discoligamentous injury without fracture may be unnoticeable on PMCT because signs of cervical misalignment change depending on the posture of the neck at the time of postmortem imaging. Because of its greater sensitivity for soft tissue injury, PMMRI is especially useful for detecting pathological changes in cases of death due to cervical discoligamentous injury. In this paper, findings on postmortem imaging for this injury are described in detail and correlated with findings on autopsy.
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Affiliation(s)
- Takahisa Okuda
- Department of Legal Medicine, Nippon Medical School, Tokyo, Japan.
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Clinical review: Spinal imaging for the adult obtunded blunt trauma patient: update from 2004. Intensive Care Med 2012; 38:752-71. [PMID: 22407141 DOI: 10.1007/s00134-012-2485-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 12/13/2011] [Indexed: 12/22/2022]
Abstract
PURPOSE Controversy exists over how to 'clear' (we mean enable the clinician to safely remove spinal precautions based on imaging and/or clinical examination) the spine of significant unstable injury among clinically unevaluable obtunded blunt trauma patients (OBTPs). This review provides a clinically relevant update of the available evidence since our last review and practice recommendations in 2004. METHODS Medline, Embase. Google Scholar, BestBETs, the trip database, BMJ clinical evidence and the Cochrane library were searched. Bibliographies of relevant studies were reviewed. RESULTS Plain radiography has low sensitivity for detecting unstable spinal injuries in OBTPs whereas multidetector-row computerised tomography (MDCT) approaches 100%. Magnetic resonance imaging (MRI) is inferior to MDCT for detecting bony injury but superior for detecting soft tissue injury with a sensitivity approaching 100%, although 40% of such injuries may be stable and 'false positive'. For studies comparing MDCT with MRI for OBTPs; MRI following 'normal' CT may detect up to 7.5% missed injuries with an operative fixation in 0.29% and prolonged collar application in 4.3%. Increasing data is available on the complications associated with prolonged spinal immobilisation among a population where a minority have an actual injury. CONCLUSIONS Given the variability of screening performance it remains acceptable for clinicians to clear the spine of OBTPs using MDCT alone or MDCT followed by MRI, with implications to either approach. Ongoing research is needed and suggestions are made regarding this. It is essential clinicians and institutions audit their data to determine their likely screening performances in practice.
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Gawor G, Biese K, Platts-Mills TF. Delay in spinal cord injury diagnosis due to sedation: a case report. J Emerg Med 2012; 43:e413-8. [PMID: 22244601 DOI: 10.1016/j.jemermed.2011.05.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 10/08/2010] [Accepted: 05/20/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND In the United States, the incidence of traumatic spinal cord injury is estimated to be approximately 40 per one million persons per year. The most common causes of traumatic spinal cord injury are motor vehicle collisions, falls, gunshot wounds, and sports accidents. OBJECTIVE To report signs, symptoms, clinical presentation, diagnostic modalities, acute management, and treatment of an acute spinal cord injury. CASE REPORT A case of traumatic cervical spine injury that was not immediately apparent upon presentation is reported. Diagnostic confirmation was possible after obtaining magnetic resonance imaging and after the sedative effects of medications resolved, allowing for a better physical examination. CONCLUSION Neurogenic shock should be considered in patients with hypotension of unknown or unclear etiology. A ground-level fall is sufficient to cause traumatic spinal cord injury in elderly patients, and a cervical spine computed tomography scan without clear fracture does not exclude this pathology.
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Affiliation(s)
- Greg Gawor
- Residency Program, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599-7594, USA
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Carter KJ, Dunham CM, Castro F, Erickson B. Comparative analysis of cervical spine management in a subset of severe traumatic brain injury cases using computer simulation. PLoS One 2011; 6:e19177. [PMID: 21544239 PMCID: PMC3081343 DOI: 10.1371/journal.pone.0019177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 03/29/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND No randomized control trial to date has studied the use of cervical spine management strategies in cases of severe traumatic brain injury (TBI) at risk for cervical spine instability solely due to damaged ligaments. A computer algorithm is used to decide between four cervical spine management strategies. A model assumption is that the emergency room evaluation shows no spinal deficit and a computerized tomogram of the cervical spine excludes the possibility of fracture of cervical vertebrae. The study's goal is to determine cervical spine management strategies that maximize brain injury functional survival while minimizing quadriplegia. METHODS/FINDINGS The severity of TBI is categorized as unstable, high risk and stable based on intracranial hypertension, hypoxemia, hypotension, early ventilator associated pneumonia, admission Glasgow Coma Scale (GCS) and age. Complications resulting from cervical spine management are simulated using three decision trees. Each case starts with an amount of primary and secondary brain injury and ends as a functional survivor, severely brain injured, quadriplegic or dead. Cervical spine instability is studied with one-way and two-way sensitivity analyses providing rankings of cervical spine management strategies for probabilities of management complications based on QALYs. Early collar removal received more QALYs than the alternative strategies in most arrangements of these comparisons. A limitation of the model is the absence of testing against an independent data set. CONCLUSIONS When clinical logic and components of cervical spine management are systematically altered, changes that improve health outcomes are identified. In the absence of controlled clinical studies, the results of this comparative computer assessment show that early collar removal is preferred over a wide range of realistic inputs for this subset of traumatic brain injury. Future research is needed on identifying factors in projecting awakening from coma and the role of delirium in these cases.
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Affiliation(s)
- Kimbroe J Carter
- Medical Decision Making Society of Youngstown Ohio, St. Elizabeth Health Center, Youngstown, Ohio, United States of America.
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Abstract
OBJECTIVE To compare head motions that occur when trained professionals perform the head squeeze (HS) and trap squeeze (TS) C-spine stabilization techniques. DESIGN Cross-over design. PARTICIPANTS Twelve experienced lead rescuers. MAIN OUTCOME MEASURES Peak head motion with respect to initial conditions using inertial measurement units attached to the forehead and trunk of the simulated patient. We compared both HS and TS during lift-and-slide (L&S) and log-roll (LR) placement on spinal board, and agitated patient trying to sit up (AGIT-Sit) or rotate his head (AGIT-Rot). The a priori minimal important difference (MID) was 5 degrees for flexion or extension and 3 degrees for rotation or lateral flexion. RESULTS The L&S technique was statistically superior to the LR technique. The only differences to exceed the MID were extension and rotation during LR (HS > TS). In the AGIT-Sit test scenario, differences in motion exceeded MID (HS > TS) for flexion, rotation, and lateral flexion. In the AGIT-Rot scenario, differences in motion exceeded MID for rotation only (HS >TS). There was similar intertrial variability of motion for HS and TS during L&S and LR but significantly more variability with HS compared with TS in the agitated patient. CONCLUSIONS The L&S is preferable to the LR when possible for minimizing unwanted C-spine motion. There is little overall difference between HS and TS in a cooperative patient. When a patient is confused, the HS is much worse than the TS at minimizing C-spine motion.
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Kelly JC, O'Briain DE, Kelly GA, Mc Cabe JP. Imaging the spine for tumour and trauma--a national audit of practice in Irish hospitals. Surgeon 2011; 10:80-3. [PMID: 22385529 DOI: 10.1016/j.surge.2011.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 01/05/2011] [Accepted: 01/20/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE The provision of appropriate spinal imaging in cases of acute injury as a consequence of trauma or tumour is becoming ever more challenging. This study assessed the use of multimodal radiological investigations in the management of spinal cord compression as a result of trauma and metastatic cancer in all major Irish hospitals. METHODS We conducted a questionnaire of thirty four hospitals in an effort to assess the provision of these services to patients with possible spinal cord compromise. In all public hospitals the Emergency Department and/or the Orthopaedic Registrars were contacted and asked a series of questions relating to spinal clearance, spinal clearance protocols, CT and MRI scanning facilities and on site orthopaedic services. RESULTS All centres participated in the study. 67.64% of centres routinely used a protocol in spinal clearance. In 87% of hospitals the Emergency department were responsible for clearing the spine. 85.3% of hospitals had CT availability during normal working hours (9-5) dropping to 47% availability after hours. MRI was available in 50% of hospitals, with surprisingly just two centres providing out of hours MRI imaging services. CONCLUSION The provision of radiological services in the management of suspected spinal injuries in Irish hospitals is inadequate in comparison to international best practice. This is most marked in relation to CT and MRI.
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Affiliation(s)
- J C Kelly
- Department of Orthopaedic Surgery, Galway University Hospitals, Galway, Ireland.
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Wadhwa R, Shamieh S, Haydel J, Caldito G, Williams M, Nanda A. The role of flexion and extension computed tomography with reconstruction in clearing the cervical spine in trauma patients: a pilot study. J Neurosurg Spine 2011; 14:341-7. [PMID: 21250811 DOI: 10.3171/2010.11.spine09870] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT As a result of spinal trauma, approximately 12,000 individuals become quadriplegic or paraplegic each year in the US. The cervical spine is the most frequently injured part of the spinal column, and approximately 60% of spinal cord injuries involve the cervical region. The cervical collar remains the best method of prehospital spinal stabilization. Following trauma, difficulty securing an airway, the shielding of life-threatening injuries, and pressure ulcers are just a few of the serious problems that may be encountered in patients placed in cervical collars. The authors' goal was to develop an efficient method of clearing the cervical spine, by incorporating flexion and extension CT scanning with reconstruction (FECTR) into a trauma protocol. METHODS This prospective study reviewed consecutive patients evaluated by the neurosurgery and trauma services who underwent FECTR. Imaging studies were reviewed using the Picture Activating and Communication System. The incidence of injury detection was recorded, and detection of otherwise-missed cervical spinal injuries using FECTR and CT scanning were also recorded. This technique was also applied, without causing any new neurological complications, for comatose patients if the original CT showed no suspicion of unstable injury. The study end point was determination of the presence of cervical spinal column injury that would pose a threat of instability or injury to the patient. RESULTS Seventy-seven consecutive patients who underwent FECTR were identified. Far superior visualization of the cervicothoracic junction was achieved compared with flexion-extension cervical spine radiographs. In this case series, the sensitivity and specificity, respectively, of both FECTR and CT were 80% and 98.6% for all radiographic abnormalities. More importantly, for clinically unstable injuries, FECTR had a sensitivity of 100%. The use of FECTR added approximately 10-12 minutes to the time required for CT scanning. CONCLUSIONS The authors' initial findings show FECTR to be a safe, effective, and efficient method of posttraumatic cervical spine clearance. In unconscious or obtunded patients, FECTR facilitates cervical spine clearance with a high degree of accuracy. A larger prospective study is needed to confirm these findings.
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Affiliation(s)
- Rishi Wadhwa
- Department of Neurosurgery, Louisiana State University Health Sciences Center–Shreveport, Louisiana 71130-3932, USA
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Abstract
This is a systemic review of the published evidence regarding cervical spine management in unconscious trauma patients. We examine the literature in the following sections: use of plain radiography; use of flexion/extenson views; use of computed tomography; use of magnetic resonance imaging. We also review surveys of practice and current guidelines. In contrast to the conscious trauma patient there have been no large prospective multicentre studies to derive a clinical decision rule for the exclusion of cervical spine injury. This review therefore assesses currently available evidence to reach a logical conclusion regarding the most appropriate imaging strategy to exclude significant injury in the cervical spine, whilst minimising the time that a patient needs to remain immobilised.
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Affiliation(s)
- Julian Blackham
- Department of Emergency Medicine, University Hospitals, NHS Foundation Trust, Bristol, UK, Air Operations, Great Western Ambulance Services, NHS Trust, UK
| | - Jonathan Benger
- Department of Emergency Medicine, University Hospitals, NHS Foundation Trust, Bristol, UK, Air Operations, Great Western Ambulance Services, NHS Trust, UK, Department of Emergency Care, University of the West of England, Bristol, UK, Clinical Effectiveness Committee, College of Emergency Medicine, UK,
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Diagnosis of Unstable Cervical Spine Injuries: Laboratory Support for the Use of Axial Traction to Diagnose Cervical Spine Instability. ACTA ACUST UNITED AC 2010; 69:889-95. [DOI: 10.1097/ta.0b013e3181bbd660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Extrication Collars Can Result in Abnormal Separation Between Vertebrae in the Presence of a Dissociative Injury. ACTA ACUST UNITED AC 2010; 69:447-50. [DOI: 10.1097/ta.0b013e3181be785a] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The goal of cervical spine clearance is to establish that injuries are not present. Patients are classified into four groups: asymptomatic, temporarily nonassessable secondary to distracting injuries or intoxication, symptomatic, and obtunded. Level I evidence supports that the asymptomatic patient can be cleared on clinical grounds and does not require imaging. The temporarily nonassessable patient may have short-term mental status changes (eg, intoxication, painful distracting injuries) and can be evaluated by two methods. When there is urgency, the evaluation is similar to that for the obtunded patient. Alternatively, the patient can be reevaluated within 24 to 48 hours, after return of mentation or following treatment of painful injuries. The patient then can be assessed as the asymptomatic patient is. The symptomatic patient requires advanced imaging. The obtunded patient should undergo, at minimum, a multidetector CT scan. Two methods are advocated. One uses only multidetector CT; a normal result is sufficient to clear the obtunded patient. The alternative method is obtaining a magnetic resonance image subsequent to a negative multidetector CT scan. Because at present information is insufficient to determine whether MRI is indicated, this is an area of controversy.
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Threat of Ambulance Car Bombs Arriving at Hospitals and Other Mass-Casualty Scenes—Intelligence Review and Methods for Mitigation. Prehosp Disaster Med 2010. [DOI: 10.1017/s1049023x00022263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Unrecognized ligamentous instability due to high-energy, low-velocity mechanism of injury. J Clin Neurosci 2010; 17:139-41. [DOI: 10.1016/j.jocn.2009.02.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 02/14/2009] [Accepted: 02/17/2009] [Indexed: 12/13/2022]
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Traumatic cervical discoligamentous injuries: correlation of magnetic resonance imaging and operative findings. Spine (Phila Pa 1976) 2009; 34:2754-9. [PMID: 19940733 DOI: 10.1097/brs.0b013e3181b6170b] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review using prospectively collected data. OBJECTIVE The purpose of the study was to investigate the diagnostic properties of cervical magnetic resonance imaging (MRI) in detecting surgically verified disruptions of the anterior longitudinal ligament (ALL), intervertebral disc, and posterior longitudinal ligament (PLL). SUMMARY OF BACKGROUND DATA Cervical MRI findings commonly provide the basis for the decision to stabilize cervical injury operatively. The correlation of cervical MRI findings with direct visualization of the cervical discoligamentous structures during operative management is a subject of debate. METHODS The cervical spine MRI scans of patients who subsequently underwent anterior surgical stabilization after traumatic discoligamentous injury of the cervical spine were reviewed. The level and severity of ALL, disc and PLL disruption was compared with surgical findings. The sensitivity, specificity, positive and negative predictive values of MRI in the detection of surgically verified injuries were calculated. RESULTS The MRI and surgical findings were compared on 31 consecutive patients, with the kappa values for ALL, intervertebral disc, and PLL disruption measuring 0.22, 0.25, and 0.31, respectively. MRI scans provided reasonable sensitivity to disc disruption (0.81) but poor sensitivity to ALL (0.48) and PLL (0.50) injury. Specificity for ALL and PLL disruption was 1.00 and 0.87, respectively, but 0.00 for disc disruption. The positive predictive value of MRI for ALL and intervertebral disc injury was 1.00 and 0.96, respectively, but 0.63 for PLL disruption. The false-negative rates for disruption of the ALL, disc and PLL were 0.52, 0.19, and 0.50, respectively. CONCLUSION The ability of cervical MRI to detect surgically verified disruptions of the ALL, intervertebral disc, and PLL varied depending on the structure examined. MRI was sensitive but not specific for disc injury, and specific but not sensitive to ALL and PLL disruption. In this series, the comparison of cervical MRI and operative findings indicated that MRI was reliable only when positive for ALL and disc injury, and a reasonably reliable indicator of PLL status only when negative for PLL injury. Additionally, the high false-negative rates for ALL and PLL injury are concerning.
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Practice Management Guidelines for Identification of Cervical Spine Injuries Following Trauma: Update From the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. ACTA ACUST UNITED AC 2009; 67:651-9. [DOI: 10.1097/ta.0b013e3181ae583b] [Citation(s) in RCA: 203] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Saltzherr TP, Fung Kon Jin PHP, Beenen LFM, Vandertop WP, Goslings JC. Diagnostic imaging of cervical spine injuries following blunt trauma: a review of the literature and practical guideline. Injury 2009; 40:795-800. [PMID: 19523626 DOI: 10.1016/j.injury.2009.01.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2008] [Revised: 12/31/2008] [Accepted: 01/08/2009] [Indexed: 02/02/2023]
Abstract
Patients with a (potential) cervical spine injury can be subdivided into low-risk and high-risk patients. With a detailed history and physical examination the cervical spine of patients in the "low-risk" group can be "cleared" without further radiographic examinations. X-ray imaging (3-view series) is currently the primary choice of imaging for patients in the "low-risk" group with a suspected cervical spine injury after blunt trauma. For patients in the "high-risk"group because of its higher sensitivity a computed tomography scan is primarily advised or, alternatively, the cervical spine is immobilised until the patient can be reliably questioned and examined again. For the imaging of traumatic soft tissue injuries of the cervical spine magnetic resonance imaging is the technique of choice.
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Affiliation(s)
- T P Saltzherr
- Trauma Unit Department of Surgery, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
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