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1.
Syed Nabeel Zafar Adil H. Haider Kent A. Stevens Nik Ray-Mazumder Mehreen T. Kisat Eric B. Schneider Albert Chi Samuel M. Galvagno Jr. Edward E. Cornwell rd David T. Efron Elliott R. Haut 《Injury》2014
Background
Recent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV).Study design
We studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007–2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility.Results
74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66–85%), PV (median 11%, IQR 7–17%), or others (median 7%, IQR 2–18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p < 0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR = 2.0, 95% CI 1.73–2.35).Conclusions
Wide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question. 相似文献2.
Background
The role of routine dedicated spinal imaging and immobilisation following gunshot wounds (GSW) to the head, neck or torso has been debated. The purpose of this study was to determine the incidence of spinal column injury requiring stabilisation in evaluable patients following gunshot injury.Methods
A retrospective study from of a Level I trauma centre from January 1995 to December 2004. All patients with GSW to the head, neck or torso and bony spinal column injury underwent medical record review to determine injury type, presentation, presence of concomitant spinal cord injury, treatment and outcome.Results
A total of 4204 patients sustaining GSW to the head, neck or torso were identified. Complete medical records were available for the 327 (7.8%) patients with bony spinal column injury. Among these patients, 173 (52.9%) sustained spinal cord injury. Two patients (0.6%) with GSW to the torso and bony spinal column injury required operative spinal intervention. The indication for operative intervention in both cases was removal of a foreign body or bony fragment for decompression of the spinal canal. None of the 4204 patients sustaining GSW to the head, neck or torso demonstrated spinal instability requiring operative intervention, and only 2/327 (0.6%) required any form of operative intervention for decompression.Conclusion
Spinal instability following GSW with spine injury is very rare. Routine spinal imaging and immobilisation is unwarranted in examinable patients without symptoms consistent with spinal injury following GSW to the head, neck or torso. 相似文献3.
Background
Penetrating intracranial injuries are common in the deployed military medical environment. Early assessment of prognosis includes initial conscious level. There has been no previous identification of different outcomes depending on mechanism of penetrating injury. The aim of this study was to define outcome from penetrating head injury in our population, and to compare outcome between gunshot wound (GSW) and blast fragment injury, in order to detect a difference in survival.Methods
A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry (JTTR) between the dates 2003 and 2011 to identify all cases of penetrating head injury. Data collected included mechanism of injury, first recorded GCS, injury severity score (ISS), abbreviated injury scale (AIS) head score, concomitant extracranial injury, surgical intervention, hospital length of stay, and survival.Results
813 patients sustained a penetrating head injury, of whom 625 were injured by blast fragmentation and 188 were injured by GSW; overall 336 patients (41.3%) died. There was a significant difference between survival from GSW (41.5%) and blast fragment (63.8%; p < 0.001). In addition, the GCS in patients injured by GSW was significantly lower than that in patients injured by blast fragment. 157 cases sustained isolated head injury (79 GSW, 78 blast). The difference in injury severity between these groups was marked; median AIS was higher in the GSW group, survival lower (42% vs. 88%; p < 0.001) and distribution of GCS categories less favourable (p < 0.001). 338 of 343 patients (98.5%) with a best recorded GCS > 5, survived to discharge.Conclusion
Most patients who present following penetrating intracranial injury, who have a GCS > 5, survive to discharge. There is a significant difference in survival to hospital discharge following penetrating injury caused by blast fragment compared to those caused by GSW, partly attributable to a difference in injury severity. This is the first study to specifically highlight and define this difference. 相似文献4.
Eric McCoy Nima Eftekhary Kenneth Nwosu Dudley Fukunaga Charles Liu Kevin Rolfe 《The spine journal》2017,17(12):1846-1849
Background Context
We receive a large number of patients with spinal cord injury (SCI) due to penetrating gunshot wounds (GSW) at our national rehabilitation center. Although many patients are labeled American Spinal Injury Association (ASIA) B sensory incomplete because of sensory sparing, especially deep anal pressure, with purported prognostic value, we have not observed a clinical difference from patients labeled ASIA A complete. We hypothesized that sensory sparing, if meaningful, should reduce the occurrence of pressure ulcers.Purpose
To determine if ASIA classifications A and B are important distinctions for patients with SCIs secondary to civilian gunshot wounds.Design/Setting
A retrospective chart review was performed on all patients with civilian gunshot-induced SCI transferred to Rancho Los Amigos Rehabilitation Center between 1999 and 2014. Outcome measures were occurrence of pressure ulcers and surgical intervention for pressure ulcers.Patient Sample
We included a total of 487 patients who sustained civilian gunshot wounds to the spine and were provided care at Rancho Los Amigos Rehabilitation Center from 2001 to 2014.Outcome Measures
Occurrence of pressure ulcers and surgical intervention for pressure ulcers among patients who suffered civilian-induced gunshot wounds to the spine.Methods
Retrospective chart review identified 487 SCIs due to gunshot wounds that were treated at Rancho Los Amigos from 2001 to 2014. Injury characteristics including ASIA classification, pressure ulcers, and pressure ulcer surgeries were recorded. Comprehensive surgical data were obtained for all patients. Chart reviews and telephone interviews were performed to determine the occurrence of any pressure ulcers and pressure ulcer surgeries. Statistical analysis was performed to compare data by spinal region and ASIA grade. There were no conflicts of interest from any of the authors, and there was no funding obtained for this study.Results
There was no statistical difference for cervical ASIA A versus ASIA B for the occurrence of pressure ulcers or the percentage requiring surgery, nor for thoracic A versus B. When grouped, there was a statistically higher occurrence of pressure ulcers in cervical A or B classification than in thoracic A or B classification, but a higher rate of surgery for thoracic A or B classification. Lumbosacral cauda equina levels were not statistically different in occurrence of pressure ulcers or pressureulcer surgery by ASIA grades A–D. Overall, when grouped C1–T12, cord-level cervicothoracic A and B classifications were statistically equivalent. C1–T12 cord level C or D classification with motor sparing had statistically lower occurrence and need of surgery for pressure ulcers and were equivalent to lumbosacral cauda equina level A–D.Conclusion
ASIA A and B distinctions are not meaningful at spinal cord levels in the cervicothoracic spine due to gunshot wounds as shown by similar occurrence of pressure ulcers and pressure ulcer surgery, and should be treated as if the same. Meaningful decrease of pressure ulcers at cord levels does not occur until there is motor sparing ASIA C or D. Furthermore, cauda equina lumbosacral injuries are a lower risk, which is independent of ASIA grade A–D and statistically equivalent to cord level C or D. Motor sparing at cord levels or any cauda equina level is most determinative neurologically for the occurrence of pressure ulcers or pressure ulcer surgery. 相似文献5.
Brian M. FisherSteven Cowles B.M. Jennifer R. MatulichBradley G. Evanson B.S. Diana VegaSharmila Dissanaike M.D. 《American journal of surgery》2013
Background
Guidelines are in place directing the clearance of the cervical spine in patients who are awake, alert, and oriented, but a gold standard has not been recognized for patients who are obtunded. Our study is designed to determine if magnetic resonance imaging (MRI) detects clinically significant injuries not seen on computed tomographic (CT) scans.Methods
The trauma registry was used to identify and retrospectively review medical records of blunt trauma patients from January 1, 2005, to March 30, 2012. Only obtunded patients with a CT scan and MRI of the cervical spine were included.Results
The study cohort consisted of 277 patients. In 13 (5%) patients, MRI detected clinically significant cervical spine injuries that were missed by CT scans, and in 7 (3%) these injuries required intervention. The number needed to screen with MRI to prevent 1 missed injury was 21.Conclusions
The findings suggest that the routine use of MRI in clearing the cervical spine in the obtunded blunt trauma patient. 相似文献6.
Hirotaka Chikuda Junichi Ohya Hiromasa Horiguchi Katsushi Takeshita Kiyohide Fushimi Sakae Tanaka Hideo Yasunaga 《The spine journal》2014,14(10):2275-2280
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. 相似文献7.
Yan Ma Peter Passias Licia K. Gaber-Baylis Federico P. Girardi Stavros G. Memtsoudis 《The spine journal》2010,10(10):881-889
Background context
Despite increasing utilization of surgical spine fusions, a paucity of literature addressing perioperative complications after revision posterior spinal fusion (RPSF) versus primary posterior spine fusion (PPSF) of the thoracic and lumbar spine exists.Purpose
To examine demographics of patients undergoing PPSF and RPSF of the thoracic and lumbar spine, assess the incidence of perioperative morbidity and mortality, and determine independent risk factors for in-hospital death.Study design/setting
Analysis of nationally representative data collected for the National Inpatient Sample (NIS).Patient sample
All discharges included in the NIS with a procedure code for posterior thoracic and lumbar spine fusion from 1998 to 2006.Outcome measures
In-hospital mortality and morbidity.Methods
Data collected for each year between 1998 and 2006 for the NIS were analyzed. Discharges with a procedure code for thoracic and lumbar spine fusion were included in the sample. The prevalence of patient- as well as health care–related demographics was evaluated by procedure type (primary vs. revision). Frequencies of procedure-related complications and in-hospital mortality were analyzed. Independent predictors for in-hospital mortality were determined.Results
We identified 222,549 PPSF and 12,474 RPSF discharges between 1998 and 2006. Patients undergoing PPSF were significantly younger (51.23 years; confidence interval [CI]=51.16, 51.31) and had lower average comorbidity indices (0.40; CI=0.39, 0.41) than those undergoing RPSF (52.69 years; CI=52.43, 52.97) and (0.44; CI=0.43, 0.45), p<.0001. The incidence of procedure-related complications was 16.02% among RPSF compared with 13.44% in PPSF patients (p<.0001). In-hospital mortality rates after PPSF were approximately twice those of RPSF (0.28% vs. 0.15%, p=.006). Adjusted risk factors for increased in-hospital mortality included PPSF compared with RPSF, male gender, and increasing age. A number of comorbidities, complications, and specific surgical indications increased the risk for perioperative death.Conclusion
Despite being performed in generally younger and healthier patients and having lower perioperative morbidity, PPSF procedures are associated with increased mortality compared with RPSF procedures. The findings of this study can be used for risk stratification, accurate patient consultation, and hypothesis formation for future research. 相似文献8.
Marjorie C. Wang Mikesh Shivakoti Rodney A. Sparapani Changbin Guo Purushottam W. Laud Ann B. Nattinger 《The spine journal》2012,12(10):902-911
Background context
Readmissions within 30 days of hospital discharge are undesirable and costly. Little is known about reasons for and predictors of readmissions after elective spine surgery to help plan preventative strategies.Purpose
To examine readmissions within 30 days of hospital discharge, reasons for readmission, and predictors of readmission among patients undergoing elective cervical and lumbar spine surgery for degenerative conditions.Study design
Retrospective cohort study.Patient sample
Patient sample includes 343,068 Medicare beneficiaries who underwent cervical and lumbar spine surgery for degenerative conditions from 2003 to 2007.Outcome measures
Readmissions within 30 days of discharge, excluding readmissions for rehabilitation.Methods
Patients were identified in Medicare claims data using validated algorithms. Reasons for readmission were classified into clinically meaningful categories using a standardized coding system (Clinical Classification Software).Results
Thirty-day readmissions were 7.9% after cervical surgery and 7.3% after lumbar surgery. There was no dominant reason for readmissions. The most common reasons for readmissions were complications of surgery (26%–33%) and musculoskeletal conditions in the same area of the operation (15%). Significant predictors of readmission for both operations included older age, greater comorbidity, dual eligibility for Medicare/Medicaid, and greater number of fused levels. For cervical spine readmissions, additional risk factors were male sex, a diagnosis of myelopathy, and a posterior or combined anterior/posterior surgical approach; for lumbar spine readmissions, additional risk factors were black race, Middle Atlantic geographic region, fusion surgery, and an anterior surgical approach. Our model explained more than 60% of the variability in readmissions.Conclusions
Among Medicare beneficiaries, 30-day readmissions after elective spine surgery for degenerative conditions represent a target for improvement. Both patient factors and operative techniques are associated with readmissions. Interventions to minimize readmissions should be specific to surgical site and focus on high-risk subgroups where clinical trials of interventions may be of greatest benefit. 相似文献9.
Anil Kumar Gupta Chandan Kumar Praveen Kumar Ashok Kumar Verma Rohit Nath Chaitanya D Kulkarni 《Indian Journal of Orthopaedics》2014,48(4):366-373
Background:
Spinal cord/nerve root compression secondary to a tubercular epidural abscess leads to neurological deficit. Depending on the extent and duration of compression, the end result after treatment may vary from complete recovery to permanent deficit. ASIA has been used extensively to correlate between MRI and neurological status due to traumatic spine injuries. MRI has stood as an invaluable diagnostic tool out of the entire range of current imaging modalities. However, inspite of considerable literature on the applications of MRI in spinal tuberculosis, there have been few studies to assess the relationship between the MRI findings and the neurological deficit as assessed by clinical examination.Aims:
The objective of this study was to ascertain whether the findings of magnetic resonance imaging (MRI) correlate well with the actual neurological recovery status using the American Spinal Injury Association impairment scale (ASIA) in patients with spinal compression secondary to tuberculous spondylitis.Materials and Methods:
60 patients (mean age 43.6 years) diagnosed as spinal tuberculosis by MRI/cytology/histopathology were examined and classified into ASIA impairment scale A-E based on the ASIA and again reclassified after 6 months of therapy to assess functional recovery. Similarly, they underwent MR imaging at the start and at the completion of 6 months of therapy to assess the structural recovery. The MRI features of recovery were correlated with the actual neurological recovery as ascertained by the ASIA.Results:
Before starting treatment 1 patient (2.08%) was in ASIA A, 2 (4.16%) were in ASIA B, 9 (18.75%) were in ASIA C, 36 (75%) were in ASIA D and 12 (20%) were in ASIA E. There was a significant difference in the epidural abscess thickness, thecal compression and cord compression between ambulatory (ASIA D and ASIA E) and non ambulatory patients (ASIA A, ASIA B and ASIA C). After 6 months of therapy 30 (90%) patients in ASIA D and 5 (55.5%) in ASIA C had complete neurological recovery. Both patients from ASIA B improved to ASIA D. Single patient who was in ASIA A before treatment remained non ambulatory (ASIA C) after treatment. Overall 33 (78.5%) patients showed complete recovery at final followup. Out of all the MRI features, only size of epidural abscess was found to be a poor prognostic factor for recovery of neurological deficit.Conclusions:
There are several parameters on MRI which correlate with the severity of neurological impairment according to ASIA score and resolution of those features on treatment is also correlated well with neurological recovery. 相似文献10.
Michael C. Fu Rafael A. Buerba William D. Long III Daniel J. Blizzard Andrew W. Lischuk Andrew H. Haims Jonathan N. Grauer 《The spine journal》2014,14(10):2442-2448
Background context
Magnetic resonance imaging (MRI) is frequently used in the evaluation of degenerative conditions in the lumbar spine. The relative interrater and intrarater agreements of MRI findings across different pathologic conditions are underexplored, as most studies are focused on specific findings.Purpose
The purpose of this study was to characterize the interrater and intrarater agreements of MRI findings used to assess the degenerative lumbar spine.Study design
A retrospective diagnostic study at a large academic medical center was undertaken with a panel of orthopedic surgeons and musculoskeletal radiologists to assess lumbar MRIs using standardized criteria.Patient sample
Seventy-five subjects who underwent routine lumbar spine MRI at our institution were included.Outcome measures
Each MRI study was assessed for 10 lumbar degenerative findings using standardized criteria. Lumbar vertebral levels were assessed independently, where applicable, for a total of 52 data points collected per study.Methods
T2-weighted axial and sagittal MRI sequences were presented in random order to the four reviewers (two orthopedic spine surgeons and two musculoskeletal radiologists) independently to determine interrater agreement. The first 10 studies were reevaluated at the end to determine intrarater agreement. Images were assessed using standardized and pilot-tested criteria to assess disc degeneration, stenosis, and other degenerative changes. Interrater and intrarater absolute percent agreements were calculated. To highlight the most clinically important MRI disagreements, a modified agreement analysis was also performed (in which disagreements between the lowest two severity grades for applicable conditions were ignored). Fleiss kappa coefficients for interrater agreement were determined.Results
The overall absolute and modified interrater agreements were 76.9% and 93.5%, respectively. The absolute and modified intrarater agreements were 81.3% and 92.7%, respectively. Average Fleiss kappa coefficient was 0.431, suggesting moderate overall agreement. However, when stratified by condition, absolute interrater agreement ranged from 65.1% to 92.0%. Disc hydration, disc space height, and bone marrow changes exhibited the lowest absolute interrater agreements. The absolute intrarater agreement had a narrower range, from 74.5% to 91.5%. Fleiss kappa coefficients ranged from fair-to-substantial agreement (0.282–0.618).Conclusions
Even in a study using standardized evaluation criteria, there was significant variability in the interrater and intrarater agreements of MRI in assessing different degenerative conditions of the lumbar spine. Clinicians should be aware of the condition-specific diagnostic limitations of MRI interpretation. 相似文献11.
Kathleen M. Adelgais Lorin Browne Maija Holsti Ryan R. Metzger Shannon Cox Murphy Nanette Dudley 《Journal of pediatric surgery》2014
Background
Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs).Methods
Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression.Results
5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p < 0.05) and more frequent ICU admissions (44.3% vs. 26.1% p < 0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI = 8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI = 25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT.Conclusions
Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED. 相似文献12.
Shevonne S. Satahoo James S. Davis George D. Garcia Salman Alsafran Reeni K. Pandya Cheryl D. Richie Fahim Habib Luis Rivas Nicholas Namias Carl I. Schulman 《The Journal of surgical research》2014
Background
Evaluating the cervical spine in the obtunded trauma patient is a subject fraught with controversy. Some authors assert that a negative computed tomography (CT) scan is sufficient. Others argue that CT alone misses occult unstable injuries, and magnetic resonance imaging (MRI) will alter treatment. This study examines the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient.Methods
Records of all consecutive patients admitted to a level 1 trauma center from January 2000 to December 2011 were retrospectively analyzed. Patients directly admitted to the intensive care unit with a Glasgow Coma Scale score ≤13, contemporaneous CT and MRI, and a negative CT reading were included. The results of the cervical spine MRI were analyzed.Results
A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries.Conclusions
In the obtunded trauma patient with a negative cervical spine CT, obtaining an MRI does not appear to significantly alter management, and no unstable injuries were missed on CT scan. This should be taken into consideration given the current efforts at cost-containment in the health care system. It is one of the larger studies published to date. 相似文献13.
14.
Raj D. Rao Chirag A. Berry Narayan Yoganandan Arnav Agarwal 《The spine journal》2014,14(10):2355-2365
Background context
Motor vehicle collisions (MVC) are a leading cause of thoracic and lumbar (T and L) spine injuries. Mechanisms of injury in vehicular crashes that result in thoracic and lumbar fractures and the spectrum of injury in these occupants have not been extensively studied in the literature.Purpose
The objective was to investigate the patterns of T and L spine injuries after MVC; correlate these patterns with restraint use, crash characteristics, and demographic variables; and study the associations of these injuries with general injury morbidity and fatality.Study design/setting
The study design is a retrospective study of a prospectively gathered database.Patient sample
Six hundred thirty-one occupants with T and L (T1–L5) spine injuries from 4,572 occupants included in the Crash Injury Research and Engineering Network (CIREN) database between 1996 and 2011 were included in this study.Outcome measures
No clinical outcome measures were evaluated in this study.Methods
The CIREN database includes moderate to severely injured occupants from MVC involving vehicles manufactured recently. Demographic, injury, and crash data from each patient were analyzed for correlations between patterns of T and L spine injuries, associated extraspinal injuries and overall injury severity score (ISS), type and use of seat belts, and other crash characteristics. T and L spine injuries patterns were categorized using a modified Denis' classification to include extension injuries as a separate entity.Results
T and L spine injuries were identified in 631 of 4,572 vehicle occupants, of whom 299 sustained major injuries (including 21 extension injuries) and 332 sustained minor injuries. Flexion-distraction injuries were more prevalent in children and young adults and extension injuries in older adults (mean age, 65.7 years). Occupants with extension injuries had a mean body mass index of 36.0 and a fatality rate of 23.8%, much higher than the fatality rate for the entire cohort (10.9%). The most frequent extraspinal injuries (Abbreviated Injury Scale Grade 2 or more) associated with T and L spine injuries involved the chest (seen in 65.6% of 631 occupants). In contrast to occupants with major T and L spine injuries, those with minor T and L spine injuries showed a strikingly greater association with pelvic and abdominal injuries. Occupants with minor T and L spine injuries had a higher mean ISS (27.1) than those with major T and L spine injuries (25.6). Among occupants wearing a three-point seat belt, 35.3% sustained T and L spine injuries, whereas only 11.6% of the unbelted occupants sustained T and L spine injuries. Three-point belted individuals were more likely to sustain burst fractures, whereas two-point belted occupants sustained flexion-distraction injuries most often and unbelted occupants had a predilection for fracture-dislocations of the T and L spines. Three-point seat belts were protective against neurologic injury, higher ISS, and fatality.Conclusions
T and L spine fracture patterns are influenced by the age of occupant and type and use of seat belts. Despite a reduction in overall injury severity and mortality, seat belt use is associated with an increased incidence of T and L spine fractures. Minor T and L spine fractures were associated with an increased likelihood of pelvic and abdominal injuries and higher ISSs, demonstrating their importance in predicting overall injury severity. Extension injuries occurred in older obese individuals and were associated with a high fatality rate. Future advancements in automobile safety engineering should address the need to reduce T and L spine injuries in belted occupants. 相似文献15.
Jennifer Moliterno Clinton A. Veselis Michael A. Hershey Eric Lis Ilya Laufer Mark H. Bilsky 《The spine journal》2014,14(10):2434-2439
Background context
Lumbar metastases can result in spinal instability and mechanical radiculopathy, characterized by radicular pain produced by axial loading. This pain pattern represents a definitive symptom of neoplastic instability and may serve as a reliable indication for surgical stabilization.Purpose
We examined the results of surgical decompression and fixation in the treatment of mechanical radiculopathy.Study design/setting
A retrospective clinical study.Patient sample
An internally maintained spine neurosurgery database was queried between February 2002 and April 2010. Patients were identified and deemed eligible for inclusion in this study based on the presence of all the following: metastatic tumor, lumbar surgery, and lumbar radiculopathy.Outcome measures
Visual analog scale (VAS) of pain and Eastern Cooperative Oncology Group (ECOG) status.Methods
The Memorial Sloan-Kettering Cancer Center Department of Neurosurgery operative database was queried over an 8-year period to identify all patients with spinal metastases who underwent lumbar surgery. Only patients whose operative indication included mechanical radiculopathy were included. Pre- and postoperative pain was assessed with the VAS of pain, whereas pre- and postoperative performance status was evaluated using the ECOG.Results
Fifty-five patients were included in the cohort. L2 and L3 were the most common levels involved, and most patients underwent multilevel posterior decompression and instrumented fusion. After surgery, 98% of patients reported pain relief. A significant difference between average pre- and postoperative pain scores was found (p<.01). Overall, 41.5% of patients experienced improvement in their ECOG score postoperatively.Conclusions
Mechanical radiculopathy in patients with spinal metastases represents a highly reliable surgical indication. Spinal decompression and fixation is an effective treatment for pain palliation in this patient population. 相似文献16.
Introduction
This audit uses error theory to analyze inappropriate trauma referrals from rural district hospitals in South Africa. The objective of the study is to inform the design of quality improvement programs and trauma educational programs.Methods
At a weekly metropolitan morbidity and mortality meeting all trauma admissions to the Pietermaritzburg Metropolitan Trauma Service are reviewed. At the meeting problematic and inappropriate referrals and cases of error are identified. We used the (JCAHO) taxonomy to analyze these errors.Results
During the period July 2009–2011 we received 1512 trauma referrals from our rural hospitals. Of these referrals we judged 116 (13%) to be problematic. This group sustained a total of 142 errors. This equates to 1.2 errors per patient. There were 87 males and 29 females in this group. The mechanism of injury was as follows, blunt trauma (66), stabs (32), gunshot wounds (GSW) (13) and miscellaneous five. The types of error consisted of assessment errors (85), resuscitation errors (26), logistics errors (14) and combination errors (17). The cause of the errors was planning failure in 68% of cases and execution failure in the remaining 32% of cases. The assessment errors involved the abdomen (50), chest (9), vascular system (8) and miscellaneous (18). The resuscitation errors involved airway (4), chest (11), vascular access (8) and cervical spine immobilization (3).Conclusions
Rural areas are error prone environments. Errors of execution revolve around the resuscitation process and current trauma courses specifically address these resuscitation deficits. However planning or assessment failure is the most common cause of error with blunt trauma being more prone to error of assessment than penetrating trauma. 相似文献17.
Background
There are variations in cervical spine (CS) clearance protocols in neurologically intact blunt trauma patients with negative radiological imaging but persistent neck pain. Current guidelines from the current Eastern Association for the Surgery of Trauma include options of maintaining the cervical collar or obtaining either magnetic resonance imaging (MRI) or flexion-extension films (FEF). We evaluated the utility of FEF in the current era of routine computerized tomography (CT) for imaging the CS in trauma.Materials and methods
All neurologically intact, awake, nonintoxicated patients who underwent FEF for persistent neck pain after negative CT scan of the CS at our level I trauma center over a 13-mo period were identified. Their charts were reviewed and demographic data obtained.Results
There were 354 patients (58.5% male) with negative cervical CS CT scans who had FEF for residual neck pain. Incidental degenerative changes were seen in 37%—which did not affect their acute management. FEF were positive for possible ligamentous injury in 5 patients (1.4%). Two of these patients had negative magnetic resonance images and the other three had collars removed within 3 wk as the findings were ultimately determined to be degenerative.Conclusions
In the current era, where cervical CT has universally supplanted initial plain films, FEF appear to be of little value in the evaluation of persistent neck pain. Their use should be excluded from cervical spine clearance protocols in neurologically intact, awake patients. 相似文献18.
Background
A true gold standard to rule out a significant cervical spine injury in subset of blunt trauma patients with altered sensorium is still to be agreed upon. The objective of this study is to determine whether in obtunded adult patients with blunt trauma, a clinically significant injury to the cervical spine be ruled out on the basis of a normal multidetector cervical spine computed tomography.Methods
Comprehensive database search was conducted to include all the prospective and retrospective studies on blunt trauma patients with altered sensorium undergoing cervical spine multidetector CT scan as core imaging modality to “clear” the cervical spine. The studies used two main gold standards, magnetic resonance imaging of the cervical spine and/or prolonged clinical follow-up. The data was extracted to report true positive, true negatives, false positives and false negatives. Meta-analysis of sensitivity, specificity, negative and positive predictive values was performed using Meta Analyst Beta 3.13 software.We also performed a retrospective investigation comparing a robust clinical follow-up and/or cervical spine MR findings in 53 obtunded blunt trauma patients, who previously had undergone a normal multidetector CT scan of the cervical spine reported by a radiologist.Results
A total of 10 studies involving 1850 obtunded blunt trauma patients with initial cervical spine CT scan reported as normal were included in the final meta-analysis. The cumulative negative predictive value and specificity of cervical spine CT of the ten studies was 99.7% (99.4–99.9%, 95% confidence interval). The positive predictive value and sensitivity was 93.7% (84.0–97.7%, 95% confidence interval).In the retrospective review of our obtunded blunt trauma patients, none was later diagnosed to have significant cervical spine injury that required a change in clinical management.Conclusion
In a blunt trauma patient with altered sensorium, a normal cervical spine CT scan is conclusive to safely rule out a clinically significant cervical spine injury. The results of this meta-analysis strongly support the removal of cervical precautions in obtunded blunt trauma patient after normal cervical spine computed tomography. Any further imaging like magnetic resonance imaging of the cervical spine should be performed on case-to-case basis. 相似文献19.
Chris Moran Eva Kipen Patrick Chan Louise Niggemeyer Simon Scharf Peter Hunter Mark Fitzgerald Russell Gruen 《Injury》2013
Introduction
There is a paucity of research into the outcomes and complications of cervical spine immobilisation (hard collar or halothoracic brace) in older people.Aims
To identify morbidity and mortality outcomes using geriatric medicine assessment techniques following cervical immobilisation in older people with isolated cervical spine fractures.Patients and methods
We identified participants using an injury database. We completed a questionnaire measuring pre-admission medical co-morbidities and functional independence. We recorded the surgical plan and all complications. A further questionnaire was completed three months later recording complications and functional independence.Results
Sixteen patients were recruited over a three month period. Eight were immobilised with halothoracic brace, 8 with external hard collar. Three deaths occurred during the study. Lower respiratory tract infection was the most common complication (7/16) followed by delirium (6/16). Most patients were unable to return home following the acute admission, requiring sub-acute care on discharge. The majority of patients were from home prior to a fall, 6/16 were residing there at 3 months. Most participants had an increase in their care needs at 3 months. There was no difference in the type or incidence of complications between the different modes of immobilisation.Conclusions
Geriatric medicine assessment techniques identified the morbidity and functional impairment associated with cervical spine immobilisation. This often results in a prolonged length of stay in supported care. This small pilot study recommends a larger study over a longer period using geriatric medicine assessment techniques to better define the issues. 相似文献20.
Daniela Ohlendorf Kamilla Seebach PhD Stefan Hoerzer Sandro Nigg Stefan Kopp 《The spine journal》2014,14(10):2384-2391