Diagnosing and Managing Spinal Injury in Patients with Ankylosing Spondylitis

Background

Individuals with ankylosing spondylitis are at an increased risk of vertebral fractures. These are often unstable, leading to primary and secondary neurological injury and conferring high levels of morbidity and mortality. Fractures in these patients can occur after minimal trauma and are easily missed, with potentially disastrous consequences.

Objectives

To educate health professionals who may be involved in the initial assessment and management of ankylosing spondylitis patients with possible spinal injuries, despite not being spinal specialists.

Case Reports

We present three cases from our own hospital, which illustrate the pitfalls associated with traumatic spinal injury in ankylosing spondylitis. Case 1 shows why delayed presentation of spinal injury is common, as well as demonstrating the need for multiple imaging modalities in some patients. Case 2 is an example of primary neurological injury in this patient group, and case 3 highlights the risk of secondary neurological injury, as well as the effect of multiple comorbidities on patient outcomes.

Conclusions

It is important that staff in the Emergency Department have an understanding of the extreme caution that is needed in the management of possible spinal injuries in patients with or suspected of having ankylosing spondylitis.     

Are Plain Radiographs Sufficient to Exclude Cervical Spine Injuries in Low-Risk Adults?

Background

The routine use of clinical decision rules and three-view plain radiography to clear the cervical spine in blunt trauma patients has been recently called into question.

Clinical Question

In low-risk adult blunt trauma patients, can plain radiographs adequately exclude cervical spine injury when clinical prediction rules cannot?

Evidence Review

Four observational studies investigating the performance of plain radiographs in detecting cervical spine injury in low-risk adult blunt trauma patients were reviewed.

Conclusion

The consistently poor performance of plain radiographs to rule out cervical spine injury in adult blunt trauma victims is concerning. Large, rigorously performed prospective trials focusing on low- or low/moderate-risk patients will be needed to truly define the utility of plain radiographs of the cervical spine in blunt trauma.     

Quantifying the Risk of Spinal Injury in Motor Vehicle Collisions According to Ambulatory Status: A Prospective Analytical Study

Background

The association between ambulation at the scene of a motor vehicle collision (MVC) and spinal injury has never been quantified.

Is Sub-occipital Padding Necessary to Maintain Optimal Alignment of the Unstable Spine in the Prehospital Setting? A Preliminary Report

Background

As prehospital emergency rescuers prepare cervical spine-injured adult patients for immobilization and transport to hospital, it is essential that patients be placed in a favorable position. Previously, it was recommended that patients with cervical spine injuries be immobilized in a slightly flexed position using pads placed beneath the head. However, it is unknown how neck flexion created with pad placement affects the unstable spine.

Objective

To determine the effects of three different head positions on the alignment of unstable vertebral segments.

Methods

Five cadavers with a complete segmental instability at the C5 and C6 level were included in the study. The head was either placed directly on the ground (or spine board) or on foam pads. Three conditions were tested: no pad; pads 2.84 cm thick; and pads 4.26 cm thick. Pads were positioned beneath the head to determine their effect on spinal alignment. Anterior-posterior translation, flexion-extension motion, and axial displacement across the unstable segment were compared between conditions.

Results

Although statistical tests failed to identify any significant differences between pad conditions, some meaningful results were noted. In general, the “no pad” condition aligned the spine in a position that best replicated the intact spine.

Conclusions

Because the goal of emergency rescuers is to conserve whatever physiologic or structural integrity of the spinal cord and spinal column that remains, the outcome of this study suggests that this goal may be best achieved using the “no pad” condition. However, it is recommended that more research be conducted to confirm these preliminary findings.     

Acute Nontraumatic Spinal Intradural Hematoma in a Patient on Warfarin

Background

Nontraumatic spinal intradural extramedullary hematomas are extremely rare. When they occur, they can rapidly lead to spinal cord or cauda equina compression and have devastating consequences.

Objective

The aim here was to report a case of this rare phenomenon and discuss the etiology, imaging, management, and outcome of intradural hematomas.

Case Report

We describe the case of a 76-year-old man on warfarin therapy who presented with severe lower back pain and flaccid paraparesis. Blood tests revealed an international normalized ratio of 6.0. A magnetic resonance imaging result suggested an intradural hematoma extending from L1 to L4 and compressing the spinal cord and cauda equina. Emergency surgical decompression revealed an extensive intradural extramedullary hematoma, which was evacuated. The patient showed only minor neurologic improvement 6 months postoperatively.

Conclusions

Coagulopathy-induced spinal hemorrhage should be included in the differential diagnosis for patients presenting with signs of acute spinal cord compression.     

Motocross-associated head and spine injuries in adult patients evaluated in an emergency department

Background

Motor vehicle–related injuries (including off-road) are the leading cause of traumatic brain injury (TBI) and acute traumatic spinal cord injury in the United States.

High dose methylprednisolone in the immediate management of acute,blunt spinal cord injury: what is the current practice in emergency departments,spinal units,and neurosurgical units in the UK?

Background

The National Acute Spinal Cord Injuries Studies and the Cochrane Review advocate the administration of high dose methylprednisolone following acute traumatic spinal cord injury. However, controversy surrounds its use and approaches between different units are often inconsistent.

Methods

A questionnaire was sent to all emergency departments receiving major trauma and all specialist neurosurgical and spinal units in the UK to determine the current practice regarding the use of high dose methylprednisolone in the immediate management of acute, blunt spinal cord injuries.

Results

Of 250 emergency departments, 187 replied to the questionnaire. Twelve of the 26 departments with a neurosurgical or spinal service on site stated they received consistent advice from specialist teams. Sixty four departments had a written policy regarding the treatment of spinal injuries, which in 51 departments contained advice about the administration of methylprednisolone. Of the 128 departments who gave methylprednisolone, 88 did so only on the advice of a specialist team, with the remaining 40 giving steroids immediately on identification of the injury. Ten out of 11 spinal units replied, of whom only two advised the used of steroids. Of the 34 neurosurgical units approached, seven out of 17 responders had a policy recommending the use of steroids. Of the 10 units who did not consistently recommend the use of steroids, seven had practise that varied between consultants.

Conclusion

Currently practice varies in the UK regarding the immediate use of methylprednisolone after spinal injury. Clear guidelines need to be established to achieve a more consistent approach.     

A Significant Cervical Spine Fracture: Think of the Airway

Background

Airway compromise is a potential complication of significant cervical spine injury.

Objectives

To alert emergency physicians to be aware of possible airway collapse after serious cervical spine injury.

Case Report

We report a case of an 87-year-old man who presented to the emergency department with an unstable cervical spine fracture after a fall. He subsequently developed complete upper airway obstruction from prevertebral soft tissue swelling, requiring a cricothyrotomy after a failed intubation attempt.

Conclusion

Patients with significant blunt cervical spine trauma can be at high risk for upper airway compromise.     

Sudden asphyxia caused by retropharyngeal hematoma after blunt thyrocervical artery injury

Background

Retropharyngeal hematomas are often associated with blunt cervical spine injury. Generally, they improve with conservative treatment; however, rarely, airway obstruction occurs due to delayed swelling of retropharyngeal hematoma.

Objectives

To report a case of sudden asphyxia due to retropharyngeal hematoma caused by blunt thyrocervical artery injury.

Case Report

A 30-year-old woman was admitted to the Emergency Department of Tokai University Hospital 4 h after injury in a motor vehicle collision. On arrival, she had severe dyspnea and neck swelling; thereafter, a 26-mm-thick retropharyngeal swelling was visualized on lateral cervical plain X-ray study, extending from C1 anterior vertebrae to mediastinum. Emergency intubation was performed for the asphyxia. Because extravasation of contrast agent was observed in the hematoma on emergency contrast-enhanced computed tomography (CT) scan, emergency angiography was performed, from which we diagnosed a hemorrhage from the right thyrocervical artery.

Conclusion

If a patient with a non-displaced cervical spine injury suffers airway obstruction due to retropharyngeal hematoma, vigorous hemorrhage from a thyrocervical artery injury should be considered as the cause, and emergency contrast-enhanced CT scan of the neck should be performed after emergent tracheal intubation.     

Survival in Persons With Traumatic Spinal Cord Injury Receiving Structured Follow-Up in South India

Objective

To assess the survival in persons with traumatic spinal cord injury (SCI) receiving structured follow-up in South India.

Design

Retrospective study.

Setting

Rehabilitation center.

Participants

Persons with traumatic SCI (N=490) residing within a 100-km radius of the institute who were managed and regularly followed up by the rehabilitation center between the years 1981 and 2011.

Interventions

Not applicable.

Main Outcome Measures

Survival rates and mortality risk factors. Measures were estimated using the product limit (Kaplan-Meier) method and the Cox model.

Results

The survival rate after SCI was 86% after 5 years, 71% after 15 years, and 58% after 25 years. Survival of persons with complete high cervical injury is substantially low compared with other levels of SCI. Level of injury and extent of lesion (Frankel classification and/or American Spinal Injury Association Impairment Scale) play a significant role in predicting survival of this population.

Conclusions

Survival rates of regularly followed-up persons with SCI from this study show promising results, though survival rates are lesser when compared with studies from developed countries. Better understanding of the predictors, causes of deaths, comprehensive rehabilitation, community integration, and regular follow-up could possibly assist in improving survival rates.     

Gait adaptation during walking on an inclined pathway following spinal cord injury

Background

Individuals with incomplete spinal cord injury need to be assessed in different environments. The objective of this study was to compare lower-limb power generation in subjects with spinal cord injury and healthy subjects while walking on an inclined pathway.

Methods

Eleven subjects with spinal cord injury and eleven healthy subjects walked on an inclined pathway at their natural gait speed and at slow gait speed (healthy subjects only). Ground reaction forces were recorded by force plates embedded in the inclined pathway and a 3-D motion analysis system recorded lower-limb motions. Data analysis included gait cycle parameters and joint peak powers. Differences were identified by student t-tests.

Findings

Gait cycle parameters were lower in spinal cord injury subjects compared to healthy subjects at natural speed but similar at slow gait speed. Subjects with spinal cord injury presented lower power at the ankle, knee and hip compared to healthy subjects at natural gait speed while only the power generation at push-off remained lower when the two groups performed at similar speed.

Interpretation

The most important differences are associated with the fact that individuals with spinal cord injury walk at a slower speed, except for the ankle power generation. This study demonstrated that, even with a good motor recovery, distal deficits remain and may limit the ability to adapt to uphill and downhill walking. Inclined pathways are indicated to train patients with spinal cord injury. Clinicians should focus on the speed of uphill and downhill walking and on the use of plantar flexors.     

Destructive Cervical Spine Osteoblastoma at C5 in a Young Patient Initially Presenting with Quadriparesis: Case Report and Review of the Literature

Background

Osteoblastomas are rare benign bone tumors that are mostly found in the posterior spinal elements; about 20% are located in the cervical spine.

Objective

The case of a destructive cervical osteoblastoma at C5 is reported in a 19-year-old man who initially presented with spastic quadriparesis.

Case Report

A 19-year-old man was self-referred, reporting symptoms in keeping with a progressive spastic quadriparesis, which had suddenly developed 6 days earlier. Preceding symptoms included mild non-specific neck pain for 3 weeks. The patient was afebrile, and no ambulatory X-ray study had been performed until the time of referral. A cervical spine computed tomography (CT) scan revealed a lytic lesion involving the spinal process and the pedicles of the C5 vertebra. Cervical spine magnetic resonance imaging performed on an inpatient basis revealed a well-circumscribed, destructive lesion of the C5 vertebra, measuring approximately 3 cm. The spinal cord was significantly compressed. The patient underwent open surgical resection of the tumor through a midline posterior approach. Histopathology of the tumor specimen was in keeping with a diagnosis of osteoblastoma.

Conclusion

Neuroimaging should be performed with either conventional plain X-ray study, which seems to be sufficient in patients presenting with non-specific symptomatology related to cervical spine damage, or with advanced techniques in the case of patients with persistent neck pain or neurological deficit.     

The clinical utility of cervical range of motion in diagnosis,prognosis, and evaluating the effects of manipulation: a systematic review

Background

Clinicians commonly assess cervical range of motion (ROM), but it has rarely been critically evaluated for its ability to contribute to patient diagnosis or prognosis, or whether it is affected by mobilisation/manipulation.

Objectives

This review summarises the methods used to measure cervical ROM in research involving patients with cervical spine disorders, reviews the evidence for using cervical ROM in patient diagnosis, prognosis, and evaluation of the effects of mobilisation/manipulation on cervical ROM.

Data sources and study selection

A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted, addressing one of four constructs related to cervical ROM: measurement, diagnosis, prognosis, and the effects of mobilisation/manipulation on cervical ROM.

Study appraisal and synthesis

Two independent raters appraised methodological quality using the QUADAS-2 tool for diagnostic studies, the QUIPS tool for prognostic studies and the PEDro scale for interventional studies. Heterogeneity of studies prevented meta-analysis.

Results

Thirty-six studies met the criteria and findings showed there is limited evidence for the diagnostic value of cervical ROM in cervicogenic headache, cervical radiculopathy and cervical spine injury. There is conflicting evidence for the prognostic value of cervical ROM, though restricted ROM appears associated with negative outcomes while greater ROM is associated with positive outcomes. There is conflicting evidence as to whether cervical ROM increases or decreases following mobilisation/manipulation.

Conclusion and implications of key findings

Cervical ROM has value as one component of assessment, but clinicians should be cautious about making clinical judgments primarily on the basis of cervical ROM.

Funding

This collaboration was supported by an internal grant from the Faculty of Health, The University of Newcastle.     

Suicide Mortality After Spinal Cord Injury in the United States: Injury Cohorts Analysis

Objectives

To compare 12-year suicide-specific mortalities of 3 different injury cohorts, identify the risk factors for suicide mortality after spinal cord injury (SCI), and investigate whether suicide mortality is higher among those with SCI than in the general population.

Design

Retrospective cohort study.

Setting

United States hospitals (n=28) designated as SCI Model Systems.

Participants

Participants (N=31,339) injured between January 1, 1973, and December 31, 1999.

Interventions

Not applicable.

Main Outcome Measure

Suicide death after SCI.

Results

The crude annual suicide mortality rate during the first 12 years after SCI was 91 per 100,000 person-years for 1973 to 1979 injury cohort, 69 per 100,000 person-years for 1980 to 1989 injury cohort, and 46 per 100,000 person-years for 1990 to 1999 injury cohort. Suicide mortality was associated with race, injury severity, and years since injury. The standardized mortality ratios for the 3 cohorts were 5.2, 3.7, and 3.0, respectively.

Conclusions

Suicide mortality among those with SCI decreased over 3 injury cohorts, but it still remained 3 times higher than that of the general population.     

A Comparison of Robotic Walking Therapy and Conventional Walking Therapy in Individuals With Upper Versus Lower Motor Neuron Lesions: A Randomized Controlled Trial

Objective

To compare a walking reeducation program with robotic locomotor training plus overground therapy (LKOGT) to conventional overground training (OGT) in individuals with incomplete upper motor neuron (UMN) or lower motor neuron (LMN) injuries having either traumatic or nontraumatic nonprogressive etiology.

Design

Randomized open controlled trial with blind evaluation by an independent observer.

Setting

An inpatient spinal cord injury rehabilitation center.

Participants

A total of 88 adults within 6 months of spinal cord injury onset (group A, 44 with UMN injury, and group B, 44 with LMN injury) were graded on the American Spinal Injury Association Impairment Scale as C or D. Each of these groups was then randomly allocated to conditions 1 or 2.

Interventions

Condition 1: Subgroups A1 and B1 were treated with LKOGT for 60 minutes. Condition 2: Subgroups A2 and B2 received 60 minutes of conventional OGT 5 days per week for 8 weeks. Subjects with UMN and LMN were randomized into 2 training groups.

Main Outcome Measures

Ten-meter walk test and 6-minute walk test (6MWT). Walking Index for Spinal Cord Injury II, lower extremity motor score (LEMS), and the FIM-Locomotor were secondary outcome measures.

Results

By using the LKOGT program compared with OGT, we found significant differences in the 6MWT for groups A1 and B1. LKOGT also provided higher scores than did OGT in secondary outcomes such as the LEMS and the FIM-Locomotor.

Conclusions

Robotic-assisted step training yielded better results in the 6MWT and the LEMS in patients with UMN and LMN.     

Laryngeal Injury and Pneumomediastinum Due to Minor Blunt Neck Trauma: Case Report

Background

Serious isolated laryngeal injuries are uncommon in children.

The effects of sleep on the relationship between brain injury severity and recovery of cognitive function: A prospective study

Background

Disturbed sleep pattern is a common symptom after head trauma and its prevalence in acute traumatic brain injury (TBI) is less discussed. Sleep has a profound impact on cognitive function recovery and the mediating effect of disturbed sleep on cognitive function recovery has not been examined after acute TBI.

Objectives

To identify the prevalence of disturbed sleep in mild, moderate, and severe acute TBI patients, and to determine the mediating effects of sleep on the relationship between brain injury severity and the recovery of cognitive function.

Design

A prospective study design.

Setting

Neurosurgical wards in a medical center in northern Taiwan.

Participants

Fifty-two acute TBI patients between the ages of 18 and 65 years who had received a diagnosis of TBI for the first time, and were admitted to the neurosurgical ward.

Method

The severity of brain injury was initially determined using the Glasgow Coma Scale. Each patient wore an actigraphy instrument on a non-paralytic or non-dominated limb for 7 consecutive days. A 7-day sleep diary was used to facilitate data analysis. Cognitive function was assessed on the first and seventh day after admission based on the Rancho Los Amigos Levels of Cognitive Functioning.

Results

The mild (n = 35), moderate (n = 7) and severe (n = 10) TBI patients exhibited poorer sleep efficiency, and longer total sleep time (TST) and waking time after sleep onset, compared with the normative values for the sleep-related variables (P < .05 for all). The severe and moderate TBI patients had longer daytime TST than the mild TBI patients (P < .001), and the severe TBI patients had longer 24-h TST than the mild TBI patients (P = .001). The relationship between the severity of brain injury and the recovery of cognition function was mediated by daytime TST (t = −2.65, P = .004).

Conclusions

Poor sleep efficiency, prolonged periods of daytime sleep, and a high prevalence of hypersomnia are common symptoms in acute TBI patients. The duration of daytime sleep mediates the relationship between the severity of brain injury and the recovery of cognition function.     

Videolaryngoscopy with Glidescope Reduces Cervical Spine Movement in Patients with Unsecured Cervical Spine

Background

Unconscious patients with severe trauma often require urgent endotracheal intubation. In trauma victims with possible cervical spine injury, any movement of the head and neck should be avoided.

Study Objectives

We investigated the effect of GlideScope videolaryngoscopy on cervical spine movement compared with conventional laryngoscopy in anesthetized patients with unsecured cervical spines.

Methods

Sixty patients scheduled for elective surgery with general anesthesia and without anticipated airway problems were enrolled in the study after ethics committee approval and written informed consent. Intubation was performed with videolaryngoscopy (GlideScope^®, Verathon Inc., Bothell, WA) or conventional laryngoscopy (MacIntosh). Using video motion analysis with a lateral view, the maximum extension angle α was measured with reference to anatomical points (baseline and line drawn from processus mastoideus to os frontale [glabella]). Values were analyzed using Mann Whitney U-tests.

Results

The deviation of α was a median 11.8° in the videolaryngoscope group and 14.3° in the conventional group (p = 0.045), with a maximum of 19.2° (videolaryngoscopy) vs. 29.3° (conventional). Intubation by physicians with some experience in videolaryngoscopy was associated with a reduced angle deviation (α = 10.3°) compared to inexperienced physicians (12.8°, p = 0.019). Intubation time was a median 24 s (min/max 12/75 s) in the MacIntosh group and 53 s (min/max 28/210 s) in the GlideScope group. In 3 patients randomized to the conventional group in whom conventional intubation failed, intubation could be successfully performed using videolaryngoscopy.

Conclusion

GlideScope videolaryngoscopy reduces movements of the cervical spine in patients with unsecured cervical spines and therefore might reduce the risk of secondary damage during emergency intubation of patients with cervical spine trauma.     

Effects of sensorimotor trunk impairments on trunk and upper limb joint kinematics and kinetics during sitting pivot transfers in individuals with a spinal cord injury

Background

Depending on the level and severity of the sensorimotor impairment in individuals with a spinal cord injury, the subsequent reduced seated postural stability and strength generating-capacity at the upper limbs could affect performance during sitting pivot transfer. This study aimed to determine the effects of sensorimotor impairments on head, trunk and upper limb movement and efforts during sitting pivot transfers.

Methods

Twenty-six individuals with a spinal cord injury participated and were stratified in two subgroups: with (N = 15) and without voluntary motor control (N = 11) of their lower back and abdominal muscles. Kinematics and kinetics of sitting pivot transfer were collected using a transfer assessment system. Mean joint angles and movement amplitudes and peak and average joint moments were compared between subgroups using independent Student t-tests (P < 0.05) for the weight-bearing sitting pivot transfer phases.

Findings

The subgroup without voluntary control of their lower back and abdominal muscles had significantly greater forward trunk flexion compared to the other subgroup resulting in higher wrist extension and elbow flexion at both upper limbs. No significant joint moment difference was found between the subgroups.

Interpretation

Individuals with spinal cord injury who have no voluntary motor control of their abdominal and lower back muscles increase forward trunk flexion during sitting pivot transfers 1) to increase stiffness of their spine that may optimize the strength-generating ability of their thoracohumeral muscles and 2) to lower their center of mass that may facilitate lift-off and enhance the overall stability during sitting pivot transfers.