Early management of war missile spine and spinal cord injuries: experience with 21 cases

Between 1991 and 1994, 21 patients with war missile injuries of the spine and spinal cord were treated; there were 17 men and four women, with a mean age 30.7 years; 52.4 per cent were civilians. The wounds were caused by shells (54.6 per cent) and bullets (45.4 per cent). The thoracic and lumbar spines were most commonly injured, and the injuries were frequently associated with lesions of other organs (47.6 per cent). There was extensive initial neurological deficit (tetraplegia, paraplegia) in 47.6 per cent of cases in whom there was no postoperative neurological recovery. All patients were treated operatively and associated injuries of other organs received priority management. A decompressive laminectomy was performed in 80.9 per cent of patients. Penetrating injuries of the dura were recorded in 61.9 per cent, while the spinal cord was injured in 28.5 per cent of patients. The dural defect was reconstructed in these patients. There was a low incidence of postoperative complications (14.5 per cent) which emphasizes the importance of early surgery.     

Computed tomography in the management of spinal cord arteriovenous malformations

This is a report of two cases of intramedullary arteriovenous malformations (AVMs) where computed tomography (CT) was used as a complementary diagnostic investigation. CT scan features in these two cases are briefly discussed.     

Computed tomography has an important role in hollow viscus and mesenteric injuries after blunt abdominal trauma

Introduction

Computed tomographic (CT) scans have become invaluable in the management of patients with blunt abdominal trauma. No clear consensus exists on its role in hollow viscus injuries (HVI) and mesenteric injuries (MI). The aim of this study was to correlate operative findings of HVI and MI to findings on pre-operative CT.

Methods

All patients treated for blunt abdominal trauma at Tan Tock Seng Hospital from January 2003 to January 2008 were reviewed. CT scans were only performed if the patients were haemodynamically stable and indicated. All scans were performed with intravenous contrast using a 4-slice CT scanner from 2003 to December 2004 and a 64-slice CT scanner from January 2005 onwards. All cases with documented HVI/MI that underwent both CT scans and exploratory laparotomy were analysed.

Results

Thirty-one patients formed the study group, with median age of 40 (range, 22-65) years and a significant male (83.9%) predominance. Vehicular-related incidents accounted for 67.7% of the injuries and the median Injury Severity Score (ISS) was 13 (4-50).The 2 commonest findings on CT scans were extra-luminal gas (35.5%) and free fluid without significant solid organ injuries (93.5%). During exploratory laparotomy, perforation of hollow viscus (51.6%) occurred more frequently than suspected from the initial CT findings of extra-luminal gas. Other notable findings included haemoperitoneum (64.5%), and mesenteric tears (67.7%). None of our patients with HVI and MI had a normal pre-operative CT scan.

Conclusion

Our study suggests that patients with surgically confirmed HVI and MI found at laparotomy were very likely to have an abnormal pre-operative CT scan. Unexplained free fluid was a very common finding in blunt HVI/MI and is one major indication to consider exploratory laparotomy.     

Computed tomography in thoracoabdominal trauma

This study evaluates our experience with CT scanning in thoracic and abdominal trauma. It was designed to analyze the accuracy and usefulness of CT with regard to: a) type of trauma, b) location of injury, c) timing of scanning, d) timing of operative intervention, e) confirmatory findings, and f) ultimate patient outcome. Between 1978 and 1983, 2,069 CT scans were performed for trauma in our institution, of which 122 were abdominal and ten thoracic, in 98 patients. Thirty-one of these patients had operation or autopsy confirmation of the findings; for 11 patients subsequent CT was available. Abdominal scanning was positive in 48 patients. The organs most commonly injured were spleen (17 patients), pancreas (nine), kidney (11), and liver (eight). Two pancreatic scans were initially interpreted as negative, but in retrospect definite abnormalities were present. Conclusions: 1) Thoraco-abdominal CT scanning documents injury to the liver, spleen, kidney, and retroperitoneum with a high degree of accuracy. 2) CT is most useful in stable trauma patients without obvious indications for laparotomy but with abnormal findings requiring explanation. 3) CT scanning is useful in evaluating patients for delayed complications following trauma. 4) Attention to details of technique and clinical correlation are essential to avoid misinterpretation of thoracoabdominal CT scans, especially of the pancreas. 5) Use of CT scans may assist in the safe, nonoperative management of selected patients with injury limited to solid organs.     

Computed tomography in the postoperative lumbar spine

A retrospective review of computed tomograms (CT) was performed in eight patients who underwent surgery for presumed reherniation of a lumbar disc. The CT scan in the three patients with surgically proven extradural scarring and no disc herniation, demonstrated distinct characteristics of perineural fibrosis which differed markedly from the uniform changes seen on the scans of the five patients with proven herniation.     

Computed tomography and diagnostic peritoneal lavage. Complementary roles in blunt trauma.

Viewpoints regarding the use of computed tomography (CT) and diagnostic peritoneal lavage (DPL) in the evaluation of stable blunt abdominal trauma patients remain polarized and their respective roles are ill-defined. To further clarify their independent and combined value, the authors report the results of a prospective study of their use in adult patients satisfying the entry criteria of major blunt torso trauma, hemodynamic stability, equivocal and unreliable abdominal examination, and absence of both before abdominal surgery and unstable pelvic fractures. The 116 patients admitted to the study over an 11-month period were first submitted to a CT scan using a 9800 series GE scanner (General Electric Medical Systems; Milwaukee, WI). After its review with the faculty CT radiologist, the surgeon recorded his decision as to the need for the laparotomy. All patients were then subjected to DPL and the results recorded as recommending laparotomy based on finding aspiration of greater than 10 cc of blood or greater than or equal to 100,000 RBC/mm3 greater than W 500 WBC/mm3, or positive gram stain. A final decision was then formulated based on information gained from both studies. Actual need for operation or observation was recorded based on ultimate outcome in observed patients or upon findings at laparotomy. Initial laparotomy was performed in 22 patients; yet only 17 had injuries requiring repair. Unnecessary laparotomy was recommended by DPL in 15.5 percent of patients vs 0.8 percent by CT (P greater than .01), while inappropriate observation was recommended by DPL in 1.7% vs 6.9% by CT (P less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review

Purpose

Trauma patients frequently have serious chest injuries. Retained hemothoraces and persistent pneumothoraces are among the most frequent complications of chest injuries which may lead to major, long-term morbidity and mortality if these complications are not recognized and treated appropriately. Video-assisted thoracoscopy (VATS) is a well-established technique in surgical practice. The usefulness of VATS for treatment of complications after chest trauma has been demonstrated by several authors. However, there is an ongoing debate about the optimal timing of VATS.

Methods

A computerized search was conducted which yielded 450 studies reporting on the use of VATS for thoracic trauma. Eighteen of these studies were deemed relevant for this review. The quality of these studies was assessed using a check-list and the PRISMA guidelines. Outcome parameters were successful evacuation of the retained hemothorax or treatment of other complications as well as reduction of empyema rate, length of hospital stay, and hospital costs.

Results

There was only one randomized trial and two prospective studies. Most studies report case series of institutional experiences. VATS was found to be very successful in evacuation of retained hemothoraces and seems to reduce the empyema rate subsequently. Furthermore, the length of hospital stay and costs can be drastically reduced with the early use of VATS.

Conclusion

Early VATS is an effective treatment for retained hemothoraces or other complications of chest trauma. We propose a clinical pathway, in which VATS is used as an early intervention in order to prevent serious complications such as empyemas or trapped lung.     

Computed tomography in spinal dysraphism.

Computed tomography of the spine has been used to evaluate patients with spinal dysraphism. With this technique, the nature of soft-tissue masses can often be correctly diagnosed and the underlying bony anomalies clarified.     

Computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. Their combined role

We reviewed medical records and films of all 196 trauma patients who underwent computed tomography (CT) between June 1982 and October 1986 to see whether CT achieved the level of accuracy attributed to it, whether diagnostic peritoneal lavage (DPL) performed in conjunction with CT was a useful diagnostic test for blunt abdominal trauma, and whether laparotomy was mandatory when pelvic fluid collections were seen by CT after blunt trauma. A total of 36 patients underwent DPL, 29 before and seven after CT. There were seven false-negative CTs that were clinically significant. Diagnostic peritoneal lavage was positive in three patients who had false-negative CTs. Although overall accuracy was excellent, CT was not reliable in detecting bowel injury. Diagnostic peritoneal lavage was helpful in detecting injuries missed by CT. Most stable patients with moderate or large intraperitoneal fluid collections on CT accompanying solid viscus injury were treated successfully without laparotomy.     

Computed tomography of abdomen (CTA) in management of blunt abdominal trauma

We reviewed our initial 2-year experience utilizing CT of the abdomen (CTA) in the management of blunt abdominal trauma. Thirty-four of 176 patients (19%) admitted with this diagnosis during 1987-88 underwent CTA as part of their initial evaluation. All patients were hemodynamically stable. Of the 34 CTA's, 15 were negative and the remaining 19 showed positive findings. When the CTA was negative, it was correct in 14 of 15 cases (93%). One case of a perforated jejunum was missed. Of the 19 positive CTA's, 12 cases were treated by observation. The CTA diagnosed a variety of intra- and extraperitoneal injuries which were successfully managed nonoperatively. It, however, missed findings in two cases. Seven of 19 positive CTA cases underwent laparotomy. CTA missed findings in four of these cases. These errors may have been related to the quality of the CTA technique which was subsequently assessed to be suboptimal. When positive, CTA was correct in 13 of 19 cases (68%). The overall accuracy rate was 79% (27 of 34). Subsequent review of the CT scans, however, improved the accuracy rate to 88% (30 of 34). CTA was found to be a valuable adjunct to clinical monitoring in the management of blunt abdominal trauma. However, if the utilization of CTA does not include appropriate patient selection, standardized CTA technique, and accurate radiologic interpretation, there is a significant potential for serious error.     

Computed tomography in the assessment of pediatric abdominal trauma

A retrospective review was conducted to determine the clinical reliability of computed tomography(ic) (CT) in the initial evaluation of pediatric blunt abdominal trauma. Sixty patients underwent CT with infusion over the two-year study period. Seventeen injuries were identified by CT scans in 12 patients. Injuries included splenic hematoma, hepatic injury, duodenal hematoma, traumatic pancreatitis, retroperitoneal hematoma, renal pelvis laceration, and perinephric hematoma. Three patients required abdominal exploration and CT findings were confirmed in these cases. Other diagnostic studies (nuclear imaging, ultrasonography, upper gastrointestinal tract studies) that were obtained in some patients also confirmed the CT findings. Patients who had normal CT scans had unremarkable hospital courses, and none required reevaluation for missed injury. Only two CT scans were inadequate due to motion artifact.     

Airway management in the blunt trauma patient: how important is the cervical spine?

Emergency airway management in the patient with blunt trauma is a clinical dilemma. Many of these patients require immediate airway management, but each method carries its own set of risks and benefits. At the heart of the issue is the long-standing belief that oral intubation is hazardous in the presence of an unstable injury to the cervical spine. In this article, the issues surrounding selection of an appropriate technique for airway management are reviewed critically. Recommendations are made for management of the airway in this high-risk group of patients with injury to the cervical spine.     

Computed tomography of spinal and pelvic fractures

The value of computed tomography (CT) compared with conventional x-ray was assessed in 29 spinal and 9 pelvic fractures. In the so called bursting fractures of spinal vertebrae the position of bone fragments in the neural canal was shown better by CT. The neural canal was remarkably narrowed on several occasions without the patient having any clinical symptoms of root or medullary compression. In 2 patients a fracture of laminae was discernible only on CT. Vertical fractures of vertebral bodies were also difficult to distinguish on the conventional plain x-ray. CT was helpful for planning of the anterolateral decompression operation of L2 in one patient. In cases of pelvic trauma sacro iliac joint diastasis was readily shown by CT. CT was clearly better able to determine whether the fracture extended across the sacro iliac joint. Also in fractures of the iliac wings CT readily showed the internal and external surfaces which were difficult to evaluate on plain radiographic examination. In spinal and pelvic fractures CT can give useful additional information which can influence the treatment of the trauma patient.     

Anesthesia management for spine surgery using spinal navigation in combination with computed tomography

The development of a spine surgery using neuronavigation with intraoperative computed tomography (CT) is of benefit to the patient. However, the procedure also has a major impact on anesthesia management. During the procedure, the patient remains in the prone position on the CT examination table and is moved extensively during CT scans. Furthermore, there is inadequate separation between operating field and anesthetic area. Problems encountered during the procedure were patient positioning, limited patient access, long tubing, and therefore the need for adequate monitoring. We report our experience using this approach in 35 patients with spinal fracture, spinal degeneration, and tumor and describe a step-by-step anesthetic management protocol that has been developed as a guideline for use in spinal neuronavigation with intraoperative CT at our center.     

Thromboprophylaxis in spinal trauma surgery: consensus among spine trauma surgeons

Background contextAlthough there are several studies evaluating the necessity and efficacy of thromboprophylaxis after spinal trauma with or without spinal cord injury (SCI), to date there is no established standard of practice pertaining to this specific patient population with regards to venous thromboembolism (VTE) prophylaxis.PurposeTo reach a consensus opinion in the administration of thromboprophylaxis in both preoperative and postoperative care in the settings of spinal trauma and SCI.Study designA live survey on thromboprophylaxis after spinal surgery in the setting of trauma was conducted at a meeting among spine trauma surgeons.MethodsTwenty-five spine surgeons (Neurosurgeons and Orthopedic surgeons), all members of the Spine Trauma Study Group, participated in a live survey in which they attempted to reach consensus pertaining to the management of deep vein thrombosis prophylaxis in patients with spine fractures (with and without a concomitant SCI). The consensus survey consisted of a 10-item questionnaire. Chi-square test was used for group comparisons in questionnaire responses.ResultsComplete agreement was reached for the need of postoperative pharmacologic thromboprophylaxis in cervical spine injuries with SCI and anterior thoracolumbar procedures with or without SCI. Postoperative pharmacologic thromboprophylaxis after cervical spine injuries without SCI was agreed not to be needed. In cases of delayed surgery for patients with SCI, pharmacologic thromboprophylaxis was recommended to be started as soon as possible in the presurgical period. The optimal duration of pharmacologic VTE prophylaxis was determined to be 3 months. Only 53% agreement was noted for the withholding of preoperative chemical prophylaxis in cervical or thoracolumbar spinal injuries with SCI (and 68% without SCI). Only 80% of the surgeons agreed that postoperative pharmacologic thromboprophylaxis is needed after posterior thoracolumbar procedures in patients with or without SCI. The use of vena cava filter after SCI was not universally recommended.ConclusionsPostoperative pharmacologic thromboprophylaxis was opined to be unnecessary in patients with cervical spine injuries without SCI, however, it is recommended for cervical spine trauma with SCI or anterior thoracolumbar procedures irrespective of SCI. Pharmacologic thromboprophylaxis was recommended to start preoperatively as soon as possible in SCI cases or in cases with surgical delay. Pharmacologic prophylaxis was recommended to be administered for at least 3 months postinjury. Although these recommendations met complete consensus by this group, individual patient factors should also be considered in determining optimal thromboprophylaxis in this patient population. Future research recommendations on thromboprophylaxis in spinal trauma are proposed.     

Computed tomography severity index is an early prognostic tool for acute pancreatitis

BACKGROUND: Acute pancreatitis is a severe disease with unpredictable course and outcomes. It is especially hard to identify early those patients who will have a fulminant course. In a prospective observational study, we tested the hypothesis that the CT Severity Index (CTSI), established within 48hours after admission, is prognostic for morbidity and mortality and can predict the necessity for admission to an ICU. STUDY DESIGN: From January 1994 to October 2002, all patients with the diagnosis of first time acute pancreatitis underwent spiral CT with intravenous contrast within 48hours of admission. The extent of inflammation and necrosis was assessed to define the CTSI. Patients were initially managed in an ICU in a standardized fashion. Complications and mortality were registered in a systematic manner. RESULTS: Seventy-nine patients were admitted with acute pancreatitis. The overall complication rate was 57%; mortality was 9%. In patients with a CTSI of 0 to 3, these rates were 42% and 2%, respectively; in those with CTSI of 4 to 6, 81% and 19%, respectively; and in those with CTSI of 7 to 10, 100% and 33%, respectively. Outcomes of subsequent CT scans did not alter the initial prognosis. Early CTSI correlated well with the incidence of complications, sepsis, mortality, and necessity for ICU admission. CONCLUSIONS: Acute pancreatitis is associated with marked morbidity and mortality. Initial admission to an ICU and standardized conservative treatment are justified for all patients. Early establishment of the CTSI is an excellent prognostic tool for complications and mortality. Patients with a CTSI of 0 to 3 can safely be discharged from the ICU.