Detected and overlooked cervical spine injury among comatose trauma patients: from the Pennsylvania Trauma Outcomes Study

Concomitant trauma of brain and upper cervical spine: lessons in injury patterns and outcomes

PURPOSE

The literature on concomitant traumatic brain injury (TBI) and traumatic spinal injury is sparse and a few, if any, studies focus on concomitant TBI and associated upper cervical injury. The objective of this study was to fill this gap and to define demographics, patterns of injury, and clinical data of this specific population.

METHODS

Records of patients admitted at a single trauma centre with the main diagnosis of TBI and concomitant C0-C1-C2 injury (upper cervical spine) were identified and reviewed. Demographics, clinical, and radiological variables were analyzed and compared to those of patients with TBI and: (i) C3-C7 injury (lower cervical spine); (ii) any other part of the spine other than C1-C2 injury (non-upper cervical); (iii) T1-L5 injury (thoracolumbar).

RESULTS

1545 patients were admitted with TBI and an associated C1-C2 injury was found in 22 (1.4%). The mean age was 64 years, and 54.5% were females. Females had a higher rate of concomitant upper cervical injury (p = 0.046 vs non-upper cervical; p = 0.050 vs thoracolumbar). Patients with an upper cervical injury were significantly older (p = 0.034 vs lower cervical; p = 0.030 vs non-upper cervical). Patients older than 55 years old had higher odds of an upper cervical injury when compared to the other groups (OR = 2.75). The main mechanism of trauma was road accidents (RAs) (10/22; 45.5%) All pedestrian injuries occurred in the upper cervical injured group (p = 0.015). ICU length of stay was longer for patients with an upper cervical injury (p = 0.018). Four patients died in the upper cervical injury group (18.2%), and no death occurred in other comparator groups (p = 0.003).

CONCLUSIONS

The rate of concomitant cranial and upper cervical spine injury was 1.4%. Risk factors were female gender, age ≥ 55, and pedestrians. RAs were the most common mechanism of injury. There was an association between the upper cervical injury group and longer ICU stay as well as higher mortality rates. Increased understanding of the pattern of concomitant craniospinal injury can help guide comprehensive diagnosis, avoid missed injuries, and appropriate treatment.

Dual diagnosis of TBI and SCI: an epidemiological study in the pediatric population

Introduction

Dual diagnosis (DD) with traumatic brain injury (TBI) and spinal cord injury (SCI) poses clinical and rehabilitation challenges. While comorbid TBI is common among adults with SCI, little is known about the epidemiology in the pediatric population. The primary objective of this study was to evaluate the prevalence of TBI among children in the United States hospitalized with SCI. Secondary objectives were to compare children hospitalized with DD with those with isolated SCI with regards to age, gender, race, hospital length of stay, and hospital charges.

Methods

A retrospective analysis of hospital discharges among children aged 0-18 years occurring between 2016-2018 from U.S. hospitals participating in the Kids' Inpatient Database. ICD-10 codes were used to identify cases of SCI, which were then categorized by the presence or absence of comorbid TBI.

Results

38.8% of children hospitalized with SCI had a co-occurring TBI. While DD disproportionately occurred among male children (67% of cases), when compared with children with isolated SCI, those with DD were not significantly more likely to be male. They were more likely to be Caucasian. The mean age of children with DD (13.2 ± 5.6 years) was significantly less than that of children with isolated SCI (14.4 ± 4.3 years). DD was associated with longer average lengths of stay (6 versus 4 days) and increased mean total hospital charges ($124,198 versus $98,089) when compared to isolated SCI.

Conclusion

Comorbid TBI is prevalent among U.S. children hospitalized with SCI. Future research is needed to better delineate the impact of DD on mortality, quality of life, and functional outcomes.

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

Background:

The cervical spine is injured in approximately 3% of major trauma patients, and 10% of patients with serious head injury. Therefore, clearance of the cervical spine in multitrauma patients is a critically important task. This is particularly important, considering that there is a positive correlation between a Glasgow Coma Scale of <14 and cervical spine injury. Radiography is not sensitive enough to rule out cervical spine injury, especially as radiography done in the trauma setting is usually technically unsatisfactory.

Objective:

The current study aims to assess the diagnostic accuracy and prognostic significance of using bedside point-of-care ultrasound (POCUS) in traumatic cervical spine injuries compared to computed tomography (CT) as the reference standard.

Materials and Methods:

This comparative study enrolled 284 patients with severe multiple trauma at a tertiary care center between July 2017 and March 2020. The inclusion criteria included an indication of cervical spine CT scan, satisfaction of patients with participation in the study, and the lack of history of injury and severe traumatic events. The exclusion criteria were the history of a previous cervical spinal trauma, spondylosis, scoliosis, spinal tuberculosis, degenerative vertebral changes, and patients who refused to give consent to participate in research or CT scanning. The data were analyzed by SPSS software, and sensitivity, specificity, and positive predictive value (PPV)/negative predictive value (NPV) were determined based on CT findings.

Results:

The best window for the cervical spine was through the anterior triangle using the linear array probe (6–13 MHz). POCUS had a sensitivity of 78.5%, specificity of 98.4%, PPV of 93.2%, NPV of 92.8%, and accuracy of 93.2% in detecting all types of spinal injuries in comparison with CT scan as the standard modality. POCUS had a sensitivity of 100%, specificity of 92.3%, PPV of 62.3%, NPV of 100%, and accuracy of 91.7% in cases with the movement of injured particles. POCUS had a sensitivity of 32.2%, specificity of 100%, PPV of 100%, NPV of 91.4%, and accuracy of 90.8% in detecting the fracture of transverse process. POCUS had a sensitivity of 36.1%, specificity of 100%, PPV of 100%, NPV of 98.1%, and accuracy of 98.4% in ≤14-year age multitrauma patients. In comparison, the current study achieved a sensitivity of 79.4%, specificity of 95.7%, PPV of 92.1%, NPV of 86.3%, and accuracy of 88.6% in >14-year age multitrauma patients.

Conclusion:

POCUS for cervical spine is feasible using portable ultrasound machine and by neurosurgeons/radiologists/emergency physicians with basic training. It holds great potential in resource-starved settings and in unstable patients for ruling out unstable cervical spine injuries and injuries associated with the movement of fractured or dislocated particles. POCUS examination of the cervical spine was possible in the emergency setting and even in unstable patients and could be done without moving the neck. Future studies, ideally conducted as randomized control trials, are required to establish training and education standards, and to assess the feasibility and safety of POCUS as an alternative to radiography.

Assessment of Non-Routine Events and Significant Physiological Disturbances during Emergency Department Evaluation after Pediatric Head Trauma

Outcomes following pediatric traumatic brain injury (TBI) are dependent on initial injury severity and prevention of secondary injury. Hypoxia, hypotension, and hyperventilation following TBI are associated with increased mortality. The purpose of this study was to determine the association of non-routine events (NREs) during the initial resuscitation phase with these physiological disturbances. We conducted a video review of pediatric trauma resuscitations of patients with suspected TBI and Glasgow Coma Scale (GCS) scores <13. NREs were rated as "momentary" if task progression was delayed by <1 min and "moderate" if delayed by >1 min. Vital sign monitor data were used to identify periods of significant physiological disturbances. We calculated the association between the rate of overall and moderate NREs per case and the proportion of cases with abnormal vital signs using multi-variate linear regression, controlling for GCS score and need for intubation. Among 26 resuscitations, 604 NREs were identified with a median of 23 (interquartile range [IQR] 17-27.8, range 5-44) per case. Moderate delay NREs occurred in 19 resuscitations (n = 32, median 1 NRE/resuscitation, IQR 0.3-1, range 0-5). Oxygen desaturation and respiratory depression were associated with a greater rate of moderate NREs (p = 0.008, p < 0.001, respectively). We observed no association between duration of hypotension, desaturation, and respiratory depression and overall NRE rate. NREs are common in the initial resuscitation of children with moderate to severe TBI. Episodes of hypoxia and respiratory depression are associated with NREs that cause a moderate delay in task progression. Conformance with resuscitation guidelines is needed to prevent physiological events associated with adverse outcomes following pediatric TBI.

Prevalence of concomitant traumatic cranio-spinal injury: a systematic review and meta-analysis

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.

Assessment of ultrasound as a diagnostic modality for detecting potentially unstable cervical spine fractures in pediatric severe traumatic brain injury: A feasibility study

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.

A review of cervical spine injury associated with maxillofacial trauma at a UK tertiary referral centre

INTRODUCTION

The aim of this study was to determine the incidence and patterns of cervical spine injury (CSI) associated with maxillofacial fractures at a UK trauma centre.

METHODS

A retrospective analysis was conducted of 714 maxillofacial fracture patients presenting to a single trauma centre between 2006 and 2012.

RESULTS

Of the 714 maxillofacial fracture patients, 2.2% had associated CSI including a fracture, cord contusion or disc herniation. In comparison, 1.0% of patients without maxillofacial trauma sustained a CSI (odds ratio: 2.2, p=0.01). The majority (88%) of CSI cases of were caused by a road traffic accident (RTA) with the remainder due to falls. While 8.8% of RTA related maxillofacial trauma patients sustained a CSI, only 2.0% of fall related patients did (p=0.03, not significant). Most (70%) of the CSIs occurred at C1/C2 or C6/C7 levels. Overall, 455, 220 and 39 patients suffered non-mandibular, isolated mandibular and mixed mandibular/non-mandibular fractures respectively. Their respective incidences of CSI were 1.5%, 1.8% and 12.8% (p=0.005, significant). Twelve patients with concomitant CSI had their maxillofacial fractures treated within twenty-four hours and all were treated within four days.

CONCLUSIONS

The presence of maxillofacial trauma mandates exclusion and prompt management of cervical spine injury, particularly in RTA and trauma cases involving combined facial fracture patterns. This approach will facilitate management of maxillofacial fractures within an optimum time period.

Risk factors for cervical spine injury among patients with traumatic brain injury

Background:

Diagnosis of cervical spine injury (CSI) is difficult in patients with an altered level of consciousness as a result of a traumatic brain injury (TBI). Patients with TBI and older adults are at increased risk for CSI. This study examined the various risk factors for CSI among trauma patients with TBI and whether adults who were older (≥55 years) were at higher risk for CSI when they sustained a fall-related TBI.

Materials and Methods:

Data used was the 2007 National Trauma Data Bank (NTDB), National Sample Project (NSP) for adults who sustained a TBI. This dataset contains 2007 admission records from 82 level I and II trauma centers. Logistic regression was used to identify potential risk factors for CSI and to test for interaction between age and injury mechanism. Additional model variables included gender, race, Glasgow Coma Score, multiple severe injuries, hypotension and respiratory distress.

Results:

An analysis of the NTDB NSP identified 187,709 adults with TBI, of which 16,078 were diagnosed with a concomitant CSI. In motor vehicle traffic injuries, the older age group had significantly higher odds of CSI (odds ratio [OR] = 1.26 [1.15-1.39]). In fall-related injuries the older age group did not have a higher odds of CSI compared to the younger age group. Skull/face fracture, other spine fracture/dislocation, upper limb injury, thorax injury, and hypotension were significantly associated with CSI. Pelvic injuries had an inverse association with CSI (OR = 0.60 [0.54-0.67]). Black had significantly higher odds of CSI compared to Whites (OR = 1.25 [1.07-1.46]).

Conclusion:

The identification of associated injuries and factors may assist physicians in evaluating CSI in patients with TBI.

Stem cells as therapeutic vehicles for the treatment of high-grade gliomas

Stem cells have generated great interest in the past decade as potential tools for cell-based treatment of human high-grade gliomas. Thus far, 3 types of stem cells have been tested as vehicles for various therapeutic agents: embryonic, neural, and mesenchymal. The types of therapeutic approaches and/or agents examined in the context of stem cell-based delivery include cytokines, enzyme/prodrug suicide combinations, viral particles, matrix metalloproteinases, and antibodies. Each strategy has specific advantages and disadvantages. Irrespective of the source and/or type of stem cell, there are several areas of concern for their translation to the clinical setting, such as migration in the adult human brain, potential teratogenesis, immune rejection, and regulatory and ethical issues. Nonetheless, a clinical trial is under way using neural stem cell-based delivery of an enzyme/prodrug suicide combination for recurrent high-grade glioma. A proposed future direction could encompass the use of stem cells as vehicles for delivery of agents targeting glioma stem cells, which have been implicated in the resistance of high-grade glioma to treatment. Overall, stem cells are providing an unprecedented opportunity for cell-based approaches in the treatment of high-grade gliomas, which have a persistently dismal prognosis and mandate a continued search for therapeutic options.

Cervical spine clearance in the blunt trauma patient: a review of current management strategies

The risks of overlooking a cervical spine injury in a polytrauma patient still remain substantial even with the development of recent advanced radiologic imaging and practice management guidelines. Cervical spine clearance continues to pose a diagnostic dilemma to the trauma team providing care for these patients. There are several issues with legal, medical, and economic implications: which patient populations require cervical spine radiographs; which views should be obtained; is there efficacy in flexion/extension radiographs, CT scan, or MRI scans; in the obtunded patient can the absence of significant ligamentous injury be demonstrated; who should perform clearance methods and be ultimately responsible for valid clearance. The purpose of this article is to revisit current management strategies for clearance of the cervical spine and explore new findings if any, which have been accepted as standard of care by providers, faced with this challenging responsibility.