Combined high cervical spine and brain stem injuries: a complex and devastating injury in children

Background

In young children, high cervical spine injuries (HCSI) can result in inaugural reversible, cardiac arrest or apnea. We noted in children sustaining such injuries an unusual incidence of associated brain stem injuries and defined a special pattern of combined lesions.

Methods

Children with HSCI surviving inaugural cardiac arrest/apnea were selected for a retrospective analysis of a trauma data bank. Epidemiologic, clinical, and radiological characteristics, and outcome were reviewed and compared with those of the rest of the trauma population with severe neurologic injuries (defined by a Glasgow Coma Scale <8).

Results

Thirteen children with HCSI above the C3 spinal level and inaugural cardiac arrest/apnea were identified and compared with 819 severely head injured children without HSCI. Mean age was 4.7 ± 2.9 years, and median Glasgow Coma Scale was 3 (3-6) after resuscitation. Initial standard x-ray views missed spine injuries in 6 patients. Spiral computed tomographic (CT) scan showed cervical fracture-dislocations associated with diffuse brain lesions and brain stem injury in all patients. Children with combined lesions had more frequent severe facial and skull base fractures compared with the rest of the population. They also were younger and sustained more frequent severe distracting injury to the neck than the rest of the population. Mortality rate (69%) was 2.6-fold higher than that observed in children without HCSI. In survivors, none demonstrated spinal cord injury resulting in persistent peripheral neurologic deficits, but only one achieved a good recovery.

Conclusions

Combined HCSI and brain stem injuries must be suspected in young children sustaining a severe distracting injury to the craniocervical junction. Early recognition of these catastrophic injuries by systematic spiral cervical spine and brain stem computed tomographic scan evaluation is mandatory.     

Problématique de la prise en charge des traumatismes graves du rachis cervical en pays sous-développé

Background and purpose

The management of cervical spine injuries requires a multidisciplinary approach based on emergency management and rehabilitation. In our context this chain fails, especially on the post-hospital care. Our goal is to explain the difficulties we had in the management of these patients in Dakar.

Methods

This retrospective cohort study (2005–2009) included 99 patients admitted for severe cervical spinal cord injury in two hospitals in Dakar. The clinical signs, treatment and outcome were studied. The follow up was between 3 and 54 months.

Results

The average age of patients was 36.1 years and the traffic accidents were the main etiology (73.7%). Medical transport of patients was done in 65.7% with an admission average time of 64.86 hours. On admission, 57.6% of patients had Frankel score A or B. Dislocations (59.6%) and Tear drop fractures (16.2%) were the main lesions. The surgery was performed in 83.8% with a mean interval of 128.84 hours after the trauma. Outpatient rehabilitation was offered whatever the patient's neurological status. Recovery was complete in 20.2% and partial in 31.3% with a mortality rate of 37.4%. Most deaths occurred between 1 and 6 months (59.5%) mainly due to decubitus complications (56.8%).

Conclusion

The efficacy of the management of severe spinal cord injuries is based on reducing the preoperative time and rehabilitation.     

无骨折脱位型颈髓损伤的临床研究进展

无骨折脱位型颈髓损伤是指没有骨折或脱位的颈部创伤所导致的急性颈脊髓损伤。通常多见于儿童,具体损伤机制至今仍不明了。X线、CT检查提示颈椎无骨折脱位,MRI检查有脊髓损伤的表现。临床表现多种多样,以脊髓中央型损伤综合征常见。临床治疗可分为保守治疗和手术治疗,如何选择合适的治疗方法仍存在争议。本文就无骨折脱位型颈髓损伤的病因、损伤机制、临床治疗等方面的研究进展作一综述。     

Epidemiology of traumatic spine fractures

Objectives

To illustrate the correlations and effects of age, gender and cause of accident on the type of vertebral fracture and fracture distribution, as well as on the likelihood to sustain an associated injury or neurological deficit.

Design

Retrospective analysis of 562 patients with a traumatic fracture of the spine. Each patient was analysed by reviewing the medical records, the initial radiographs and CT-scans.

Setting

Level 1 trauma centre from 01/1996 to 12/2000.

Results

The most common cause of accident was a high-energy fall (39%), followed by traffic accidents (26.5%). While fall related fractures were evenly distributed over the whole spine, traffic accidents induced significantly more fractures of the cervical and thoracic spine. Sixty-five percent of all cervical spine fractures and 80% of the multisegmental injuries were accompanied by an associated injury. The highest incidence of associated injuries was observed in patients with multilevel fractures (96.5%). Patients with a concomitant injury were more likely to sustain a spinal cord lesion. Sixty-three (11.2%) patients exhibited a complete motor and sensory deficit, 76 (13.5%) an incomplete and 423 (75.3%) no neurological deficit. The highest number of complete motor and sensory neurological deficits was found in cervical spine fractures (19.7%). The majority of patients, 308 (54.8%), sustained a compression fracture, 95 (16.9%) a distraction fracture, and 104 (18.5%) patients experienced a rotational fracture.

Conclusions

This study demonstrates correlations between the cause of accident, the type of spinal fracture and the fracture distribution. Using the AO classification, the likelihood to sustain either associated and/or spinal cord injuries, is predictable.     

Screening cervical spine MRI after normal cervical spine CT scans in patients in whom cervical spine injury cannot be excluded by physical examination

Background

Cervical spine injuries can occur in as many as 10% of patients with blunt trauma with mental status changes from closed head injuries. Despite normal results on cervical spine computed tomography (CT), magnetic resonance imaging (MRI) is often recommended to exclude ligamentous or soft tissue injury.

Methods

A retrospective review was conducted of trauma patients admitted to a level I trauma center from 2002 to 2006, in whom cervical spine injuries could not be excluded by physical examination. All patients with normal results on cervical spine CT followed by cervical spine MRI were included in the analysis.

Results

One hundred twenty patients underwent MRI to examine their cervical spines. Seven patients had abnormal MRI findings suggestive of acute traumatic injury. No MRI studies led to operative intervention. Screening MRI increased from 1% of comatose patients in 2002 to 18% in 2006.

Conclusions

The use of MRI in patients with normal results on cervical spine CT does not appear to alter treatment.     

Traumatic subaxial cervical facet subluxation and dislocation: epidemiology,radiographic analyses,and risk factors for spinal cord injury

Background Context

Distractive flexion injuries (DFIs) of the subaxial cervical spine are major contributors to spinal cord injury (SCI). Prompt assessment and early intervention of DFIs associated with SCI are crucial to optimize patient outcome; however, neurologic examination of patients with subaxial cervical injury is often difficult, as patients commonly present with reduced levels of consciousness. Therefore, it is important to establish potential associations between injury epidemiology and radiographic features, and neurologic involvement.

Morphological changes of the neural cells after blast injury of spinal cord and neuroprotective effects of sodium β-aescinate in rabbits

Objective

Explosive blast neurotrauma is becoming more and more common not only in the military population but also in civilian life due to the ever-present threat of terrorism and accidents. However, little attention has been offered to the studies associated with blast wave-induced spinal cord injury in the literatures. The purpose of this study is to report a rabbit model of explosive blast injury to the spinal cord, to investigate the histological changes, focusing especially on apoptosis, and to reveal whether β-aescinate (SA) has the neuroprotective effects against the blast injury.

Methods

Adult male New Zealand white rabbits were randomly divided into sham group, experimental group and SA group. All rabbits except the sham group were exposed to the detonation, produced by the blast tube containing 0.7 g cyclotrimethylene trinitramine, with the mean peak overpressure of 50.4 MP focused on the dorsal surface of T9-T10 level. After evaluation of the neurologic function, spinal cord of the rabbits was removed at 8 h, 1, 3, 7,14 or 30 days and the H&E staining, EM examination, DNA gel electrophoresis and TUNEL were progressively performed.

Results

The study demonstrated the occurrence of both necrosis and apoptosis at the lesion site. Moreover, the SA therapy could not only improve the neurologic outcomes (P < 0.05) but also reduce the loss of motoneuron and TUNEL-positive rate (P < 0.05).

Conclusions

In the rabbit model of explosive blast injury to the spinal cord, the coexistent apoptotic and necrotic changes in cells was confirmed and the SA had neuroprotective effects to the blast injury of the spinal cord in rabbits. This is the first report in which the histological characteristics and drug treatment of the blast injury to the spinal cord is demonstrated.     

The impact of spine stability on cervical spinal cord injury with respect to demographics,management, and outcome: a prospective cohort from a national spinal cord injury registry

Background Context

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.

Cervical cord compression by hereditary multiple exostosis: case report and review of literature

Background

Hereditary multiple exostosis (HME) is an hereditary disease, characterized by the presence of multiple osteochondromas; 7% of patients with HME have a spinal disease. Through this observation, the authors discuss the diagnostic and therapeutic aspects of this rare lesion.

Case report

A 45-year-old woman, operated 10 years ago for an exostosis of the right fibula and left femur. She has since few years paresthesia of all four limbs with distal predominance, walking fatigability kind of spinal claudication. The MRI shows a voluminous osteoma at the second cervical vertebra compressing the spinal cord. The patient was operated with macroscopically complete resection of the exostosis and C2 laminectomy.

Conclusion

The cervical exostosis associated with HME is a rare disease. The clinical symptomatology is dominated by spinal cord compression and surgical treatment allows excellent clinical results.     

Protective effect of deferoxamine on experimental spinal cord injury in rat

Objective

To observe the protective effect of deferoxamine on experimental spinal cord injury (SCI) in rats.

Methods

Sprague-Dawley rats were randomly divided into the following four groups. Control group: rats were performed laminectomy only; SCI group: rats were performed laminectomy with SCI; DFO group: rats were injected intraperitoneally a bolus of 100 mg/kg deferoxamine after SCI; vehicle group: rats were injected intraperitoneally 0.9% saline after SCI. The SCI of animal model was made by using a modified Allen's method on T₁₀. Six rats of each group were sacrificed at 4 h after injured, and the levels of free iron and malondialdehyde (MDA) of involved spinal cord segments were measured by bleomycin assay and the thiobarbituric acid (TBA) separately. The recovery of function was assessed by Modified Tarlov's scale and inclined plane method at 7, 14, 21 d after SCI. The histologic changes of the damaged spinal cord were also examined at 7 d after SCI.

Results

Following SCI, the levels of free iron and MDA were increased significantly and the Modified Tarlov's score and inclined plane angles decreased in SCI group and vehicle group. In DFO group, the levels of free iron and MDA were not increased, but the Modified Tarlov's score and inclined plane angles decreased, the histological findings were improved as well.

Conclusion

Deferoxamine can reduce the levels of free iron and lipid peroxidation, and improve the hind limb functional status of rats with spinal cord injury.     

The epidemiology of BCVI at a single state trauma centre

Background

Blunt carotid and vertebral artery injury (BCVI) is a relatively uncommon but potentially devastating injury. The aim of our study was to highlight the incidence, patterns, presentation and associations of BCVI at our institution.

Methods

Retrospective data between 1st January 2003 and 31st December 2006 was obtained from The Alfred Hospital's health information system, patient medical records and the Department of Neurosurgery's database. Injuries were graded using the Denver grading scale.

Results

67 patients (0.64%) out of 10,417 minor and major trauma admissions, were diagnosed with BCVI. 33 (49%) sustained blunt carotid and 34 (51%) sustained blunt vertebral injuries. Motor vehicle accident (MVA) was the cause in 43 out of 67. 35% had associated head injury whilst 57% had concurrent cervical spine fractures. Odds ratio analysis showed that MVA victims with concomitant upper cervical spine injury were 22.9 times more likely to suffer BCVI than those without such risk factors. Approximately 50% of patients had a Glasgow coma score of 14 or less (GCS ≤ 14). Grade 4 BCVI was most common. Stroke occurred in 22 (32%) and mortality in 14 (20%).

Conclusion

BCVI although infrequent, is a serious injury. Our study suggests that MVA patients with cervical spine fractures especially of the upper C-spine are at much higher risk of BCVI than those without such injuries.     

Imaging diagnosis of cervical spine and spinal cord injuries in children

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过伸性颈椎与颈髓损伤的MRI改变（附16例报告）

本文报告16例过伸性颈椎与颈髓损伤。通过对伤后磁共振(MRI)影像和手术治疗结果进行分析。结果表明MRI检查能显示颈部过伸性损伤后颈椎结构性损伤和颈髓损伤的程度,可为其治疗措施选择和预后判断提供可靠依据。     

Spinal injuries in children

Background/purpose

Traumatic spinal injury (TSI) is an uncommon source of morbidity and mortality in children. The aim of this study was to describe childhood TSI in a single level 1 urban pediatric trauma center.

Methods

The authors retrospectively analyzed all children younger than 14 years with TSI, treated at a level I pediatric trauma center between 1991 and 2002 (n = 406, 4% total registry). All children were stratified according to demographics, mechanisms, type and level of injury, radiologic evaluations, associated injuries, and mortality.

Results

The mean age was 9.48 ± 3.81 years. The most common overall mechanism of injury was motor vehicle crash (MVC; 29%) and ranked highest for infants. Falls ranked highest for ages 2 to 9 years. Sports ranked highest in the 10 to 14 year age group. Paravertebral soft tissue injuries were 68%. The most common injury level was the high cervical spine (O-C4). The incidence of spinal cord injury without radiologic abnormality (SCIWORA) was 6%. Traumatic brain injury (37%) was the most common associated injury. Overall mortality rate was 4% in this urban catchment.

Conclusions

TSI in children requires a different preventive and therapeutic logarithm compared with that of adults. The potential devastating nature of TSI warrants that the health care team always maintains a high index of suspicion for injury. Future prospective studies are needed to further elucidate injury patterns.     

颈椎小关节突脱位闭合复位前后椎间盘和脊髓的损伤变化

目的　观察颈椎小关节突脱位闭合复位前后椎间盘和脊髓的损伤变化。方法　 16例颈椎小关节突脱位患者 ,7例单侧小关节突脱位 ,9例双侧小关节突脱位 ,在X线透视下行颅骨牵引闭合复位 ,并于复位前后进行神经功能和颈椎MRI检查 ,比较椎间盘脱出和脊髓实质损伤的变化。结果　 16例均闭合复位成功 ,复位前 5例有明显椎间盘脱出 ,4例有椎间盘撕裂 ,7例无明显椎间盘损伤。复位成功后 ,4例椎间盘脱出仍存在 ,大小无变化 ;1例原脱出椎间盘明显缩小 ,无新椎间盘脱出发生。14例复位前后脊髓信号无变化 ,2例复位后出现MRIT2 加权高信号增强。 16例复位后无一例出现神经功能恶化。结论　颅骨牵引闭合复位不会诱发或加重椎间盘脱出 ,进而造成继发性脊髓功能损伤     

Ischemic stroke after cervical spine injury: analysis of 11,005 patients using the Japanese Diagnosis Procedure Combination database

Background context

The incidence and relevant risk of ischemic stroke after cervical spine trauma remain unknown.

Purpose

To examine the incidence of ischemic stroke during hospitalization in patients with cervical spine injury, and analyze the impact of different types of cervical spine injuries on the occurrence of ischemic stroke.

Study design

Retrospective analysis of data abstracted from the Diagnosis Procedure Combination database, a nationally representative database in Japan.

Patient sample

We included all patients hospitalized for any of the following traumas: fracture of cervical spine (International Classification of Diseases, 10th Revision codes: S120, S121, S122, S127, S129); dislocation of cervical spine (S131, S133); and cervical spinal cord injury (SCI) (S141).

Outcome measures

Outcome measures included all-cause in-hospital mortality and incidence of ischemic stroke (I63) during hospitalization.

Methods

We analyzed the effects of age, sex, comorbidities, smoking status, spinal surgery, consciousness level at admission, and type of cervical spine injury on outcomes.

Results

We identified 11,005 patients with cervical spine injury (8,031 men, 2,974 women; mean [standard deviation] age, 63.5 [18] years). According to the types of cervical spine injury, we stratified the patients into three groups: cervical fracture and/or dislocation without SCI (2,363 patients); cervical fracture and/or dislocation associated with SCI (1,283 patients); and cervical SCI without fracture and/or dislocation (7,359 patients). Overall, ischemic stroke occurred in 115 (1.0%) patients during hospitalization (median length of stay, 26 days). In-hospital death occurred in 456 (4.1%) patients. Multivariate analyses showed that ischemic stroke after cervical spine injury was significantly associated with age, diabetes, and consciousness level at admission. The highest in-hospital mortality was observed in patients with cervical fracture and/or dislocation associated with SCI (7.6%), followed by cervical SCI without fracture and/or dislocation (4.0%), and cervical fracture and/or dislocation without SCI (2.6%). Unlike mortality, risks of stroke did not vary significantly among the three groups.

Conclusions

This analysis revealed that ischemic stroke after cervical spine injury was not uncommon and was associated with increased mortality and morbidity. Occurrence of ischemic stroke was significantly associated with age, comorbidities such as diabetes, and consciousness level at admission, but not with the type of spine injury.     

Prenatal covering of the spinal cord decreases neurologic sequelae in a myelomeningocele model

Background/Purpose

Recent experience in fetal surgery to correct myelomeningocele in humans reports an early reversion of hydrocephalus and decreased need of ventricular shunting in the first months of life; however, it has not been possible to demonstrate benefit in lower extremity function. In the present work, we have tried to ascertain the impact of cord exposure on hind limb function.

Methods

Fetal rabbits with myelomeningocele (group M), treated myelomeningocele (group T), and control animals (group C) were compared at birth regarding physical examination, somatosensory-evoked potentials of the hind limbs, ventricular morphometry, and spine histology.

Results

No major difference was found between groups M and T in the physical examination. Somatosensory-evoked potentials of the hind limbs were absent in group M and present in group T, although showing a longer latency period and decreased amplitude than controls. The area of the third ventricle was significantly larger in group M than in group C; in group T, it was also somewhat larger but not significantly so. Cord histology had evident changes in group M and minor changes in group T, which resembled normal group C cord.

Conclusions

Prenatal covering of the spinal cord prevents central and peripheral neurologic deterioration in this animal model of myelomeningocele.     

The Relationship between Spinal Stenosis and Neurological Outcome in Traumatic Cervical Spine Injury: An Analysis using Pavlov's Ratio, Spinal Cord Area, and Spinal Canal Area

Background

This study examined the relationship between four radiological parameters (Pavlov''s ratio, sagittal diameter, spinal cord area, and spinal canal area) in patients with a traumatic cervical spine injury, as well as the correlation between these parameters and the neurological outcome.

Methods

A total of 212 cervical spinal levels in 53 patients with a distractive-extension injury were examined. The following four parameters were measured: Pavlov''s ratio on the plain lateral radiographs, the sagittal diameter, the spinal cord area, and the spinal canal area on the MRI scans. The Pearson correlation coefficients between the parameters at each level and between the levels of each parameter were evaluated. The correlation between the radiological parameters and the spinal cord injury status classified into four categories, A (complete), B (incomplete), C (radiculopathy), and D (normal) was assessed.

Results

The mean Pavlov''s ratio, sagittal diameter, spinal cord area and spinal canal area was 0.84, 12.9 mm, 82.8 mm² and 236.8 mm², respectively. An examination of the correlation between the radiological spinal stenosis and clinical spinal cord injury revealed an increase in the values of the four radiological parameters from cohorts A to D. Pavlov''s ratio was the only parameter showing statistically significant correlation with the clinical status (p = 0.006).

Conclusions

There was a correlation between the underlying spinal stenosis and the development of neurological impairment after a traumatic cervical spine injury. In addition, it is believed that Pavlov''s ratio can be used to help determine and predict the neurological outcome.     

Follow-up disparities after trauma: a real problem for outcomes research

Introduction

The objectives of this study were to (1) determine risk factors associated with failure to follow-up (FTF) after traumatic injury and (2) in those patients who do follow up, to determine if information within the electronic medical record (EMR) is an adequate data-collection tool for outcomes research.

Methods

A 6-year retrospective analysis was conducted on all admitted trauma patients using data from the trauma registry, National Death Index, 2000 Census Data, and the EMR. Bivariate and logistic regression analyses identified risk factors for FTF. A subgroup analysis evaluated the utility of using the EMR to determine basic functional outcomes (Glasgow outcome scale, diet, ambulation, and employment status).

Results

A total of 14,784 patients were discharged, and 61% had follow-up appointments. Lower income, higher poverty rates, and lower education were significantly (P < .05) associated with FTF. Logistic regression analysis (excluding census data) identified that older age, lower Injury Severity Score, less severe head injury, nonwhite race, blunt injury, death after discharge, zip code within 25 miles, and patients discharged to home independently predicted FTF after traumatic injury. A subgroup analysis of the EMR showed the inability to reliably determine functional outcomes.

Conclusions

There are several disparities related to follow-up after trauma. Furthermore, charting deficiencies, even with an EMR, highlight the weaknesses of data available for trauma outcomes research. Trauma process improvement programs could target patients at risk for not following up and use a structured electronic outpatient note.     

小儿颈椎及颈脊髓损伤的影像学诊断

总结小儿颈椎及颈脊髓损伤的影像学诊断经验。回顾分析 59例小儿颈椎及颈脊髓损伤 ,全部病例均常规摄颈椎正、侧位片及齿状突开口位片 ,2 5例摄断层 ,2 8例摄屈 /伸侧位片。 2 1例行CT扫描 ,2 6例行MRI检查。上颈椎损伤 4 6例 ,其中寰椎椎弓骨折 9例 ,枢椎骨折 7例 ,齿状突骨折 2 1例 ,寰椎椎弓骨折合并齿状突骨折 1例 ,寰椎横韧带断裂 8例 ;下颈椎损伤 1 1例 ,其中椎体骨折 3例 ,脱位 2例 ,骨折脱位 6例 ;多节段间隔性颈椎损伤 2例 ,无X线异常的脊髓损伤 (SCIWORA) 3例。认为影像学检查对于小儿颈椎及颈脊髓损伤的诊断具有重要价值 ,对怀疑有颈椎及颈脊髓损伤的小儿患者应常规摄颈椎正、侧位片及齿状突开口位片 ,小儿颈椎SCIWORA应常规行颈椎MRI检查