Is magnetic resonance imaging becoming the new computed tomography for cervical spine clearance? Trends in magnetic resonance imaging utilization at a Level I trauma center

The Role of Magnetic Resonance Imaging to Inform Clinical Decision-Making in Acute Spinal Cord Injury: A Systematic Review and Meta-Analysis

The clinical indications and added value of obtaining MRI in the acute phase of spinal cord injury (SCI) remain controversial. This review aims to critically evaluate evidence regarding the role of MRI to influence decision-making and outcomes in acute SCI. A systematic review and meta-analysis were performed according to PRISMA methodology to identify studies that address six key questions (KQs) regarding diagnostic accuracy, frequency of abnormal findings, frequency of altered decision-making, optimal timing, and differences in outcomes related to obtaining an MRI in acute SCI. A total of 32 studies were identified that addressed one or more KQs. MRI showed no adverse events in 156 patients (five studies) and frequently identified cord compression (70%, 12 studies), disc herniation (43%, 16 studies), ligamentous injury (39%, 13 studies), and epidural hematoma (10%, two studies), with good diagnostic accuracy (seven comparative studies) except for fracture detection. MRI findings often altered management, including timing of surgery (78%, three studies), decision to operate (36%, 15 studies), and surgical approach (29%, nine studies). MRI may also be useful to determine the need for instrumentation (100%, one study), which levels to decompress (100%, one study), and if reoperation is needed (34%, two studies). The available literature consistently concluded that MRI was useful prior to surgical treatment (13 studies) and after surgery to assess decompression (two studies), but utility before/after closed reduction of cervical dislocations was unclear (three studies). One study showed improved outcomes with an MRI-based protocol but had a high risk of bias. Heterogeneity was high for most findings (I² > 0.75). MRI is safe and frequently identifies findings alter clinical management in acute SCI, although direct evidence of its impact on outcomes is lacking. MRI should be performed before and after surgery, when feasible, to facilitate improved clinical decision-making. However, further research is needed to determine its optimal timing, effect on outcomes, cost-effectiveness, and utility before and after closed reduction.

Cervical spine trauma: impact of different imaging classification systems in the clinical decision-making

Background and aim:

Considering the high rate of mortality and permanent disability related to vertebral traumas, an early and detailed diagnosis of the trauma and subsequently an immediate and effective intervention are crucial. Cervical vertebral injury classifications guide treatment choice through a severity grade based on radiological information. The purpose of the present study was to define which imaging classification system could provide the best morphological and clinical-surgical correlations for cervical spine traumas.

Methods:

We retrospectively analyzed patients evaluated for cervical spine trauma at our Institution in the period 2015-2020. Information regarding the morphological examination (using CT and MRI), the neurological evaluation, and the therapeutic management were collected. C3-C7 fractures were classified according to the SLIC and AOSpine criteria; axial lesions were classified according to the modified AOSpine for the C1-C2 compartment and through the Roy-Camille and the Anderson D’Alonzo system for the odontoid process of the axis.

Results:

29 patients were included in the final study population. Nine patients with axial spine trauma and 21 with subaxial cervical spine trauma. A conservative approach was applied in 16 patients while nine patients underwent neurosurgery. Considering the therapeutical indications provided by the SLIC system, a 76.9% accordance was found for patients with a <4 score, while a 100% concordance was calculated for patients with a >4 score undergoing neurosurgery. Regarding the AOSspine classification, a 28.6% concordance was observed for patients classified group B being treated with a posterior neurosurgical approach, while for patients belonging to subgroup C, considered for anterior neurosurgical approach, a 66.7% accordance was calculated.

Conclusions:

The study demonstrated a better morphological correlation for the AOSpine classification in subaxial trauma and the AOSpine and Anderson D’Alonzo in axial trauma. The therapeutic indication found a better correlation in the SLIC classification for subaxial trauma and the Anderson D’Alonzo for axial ones. (www.actabiomedica.it)

A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients

BACKGROUND

Venous thromboembolism (VTE) in trauma patients carries significant morbidity and mortality. We previously described how titrating enoxaparin dosing by anti-Xa trough levels was associated with a lower VTE rate. We combined this strategy with a higher initial enoxaparin dose for a majority of patients and modified the electronic medical record (EMR) to encourage immediate dosing. We sought to determine if this systems-based approach was associated with a decrease in VTE rate.

STUDY DESIGN

A retrospective review was conducted of all trauma patients on prophylactic enoxaparin at an academic, Level I Trauma Center from 01/2013 to 05/2014 (PRE) and 06/2015 to 02/2018 (POST). The patients in PRE were prescribed enoxaparin 30 mg twice daily without dose adjustments. The patients in POST received 40 mg twice daily unless exclusion criteria applied, with doses titrated to maintain anti-Xa trough levels between 0.1 and 0.2 IU/mL.

RESULTS

There were 478 patients in the PRE and 1306 in the POST. Compared to PRE, POST patients were of similar age and were as likely to present after blunt trauma, although POST patients had lower injury severity scores (10 vs. 9, p < 0.01). The overall VTE rate was lower in POST (6.9% vs. 3.6%, p < 0.01). The adjusted risk of VTE (AOR 0.61, adjusted p = 0.04) was lower in POST and POST was independently protective for VTE (AOR 0.54; p = 0.01).

CONCLUSION

By implementing system changes to improve enoxaparin dosing after trauma, a significant reduction in VTE rate was observed. Wider application of this strategy should be considered.