Damage control of multiple injuries headed by cervica spinal cord injury

Objective ： To explore the strategy of damage control in clinical treatment of multiple injuries headed by cervical spinal cord injury. Methods： A retrospective analysis was performed in 32 patients. Cervical fractures associated with tetraplegia occurred in 18 patients, traumatic intervectebral disk hernia associated with tetraplegia in 2 patients, and cervical fractures and dislocation associated with tetraplegia in 12 patients. Seventeen cases were combined with craniocerebral injury, 7 combined with pulmonary contusion, multi-fractures of rib or hemopneumothorax, 2 combined with pelvic fracture and other 8 combined with fracture of limbs. The neural function was assessed by the American Spinal Injury Association （ASIA） scale. Results： Thirty-one patients were followed up for an average of 14 months. Of them, 10 got complete recovery, 13 obtained improvement of more than one ASIA grade, 8 did not improve, and 1 died. Conclusions ： For the emergency treatment of multiple injuries headed by cervical spinal cord injury, the damage control strategy is the principle to follow. The final operations are preferably performed within 5 to 10 days after injury so as to raise the successful rate of remedy.     

Spinal injury in major trauma: Epidemiology of 1104 cases from an Italian first level trauma center

IntroductionTraumatic spinal injuries are frequent and their management is debated, especially in major trauma patients. This study aims to describe a large population of major trauma patients with vertebral fractures to improve prevention measures and fracture management.Patients and methodsRetrospective analysis of 6274 trauma patients prospectively collected between October 2010 and October 2020. Collected data include demographics, mechanism of trauma, type of imaging, fracture morphology, associated injuries, injury severity score (ISS), survival, and death timing. The statistical analysis focused on mechanism of trauma and the search of predictive factors for critical fractures.ResultsPatients showed a mean age of 47 years and 72.5% were males. Trauma included 59.9% of road accidents and 35.1% of falls. 30.7% patients had at least a severe fracture, while 17.2% had fractures in multiple spinal regions. 13.7% fractures were complicated by spinal cord injury (SCI). The mean ISS of the total population was 26.4 (SD 16.3), with 70.7% patients having an ISS≥16. There is a higher rate of severe fractures in fall cases (40.1%) compared to RA (21.9% to 26.3%). The probability of a severe fracture increased by 164% in the case of fall and by 77% in presence of AIS≥3 associated injury of head/neck while reduced by 34% in presence of extremities associated injuries. Multiple level injuries increased with ISS rise and in the case of extremities associated injuries. The probability of a severe upper cervical fracture increased by 5.95 times in the presence of facial associated injuries. The mean length of stay was 24.7 days and 9.6% of patients died.ConclusionsIn Italy, road accidents are still the most frequent trauma mechanism and cause more cervico-thoracic fractures, while falls cause more lumbar fractures. Spinal cord injuries represent an indicator of more severe trauma. In motorcyclists or fallers/jumpers, there is a higher risk of severe fractures. When a spinal injury is diagnosed, the probability of a second vertebral fracture is consistent. These data could help the decisional workflow in the management of major trauma patients with vertebral injury.     

Severity of injury does not have any impact on posttraumatic stress symptoms in severely injured patients

Background

Due to improved surgical techniques and more efficient decision making in treating severely injured patients, survival rates have increased over the years. This study was initiated to evaluate the incidence and identify risk factors for developing posttraumatic stress symptoms, using both extensive trauma-related data and data assessing the psychological trauma, in a population of severely injured patients.

Patients and methods

79 patients admitted to the Department of Multitrauma and Spinal Cord Injury at Sunnaas Rehabilitation Hospital from 2003 to 2005, prospectively completed semistructured psychological interviews and questionnaires, such as Impact of Event Scale-Revised. In addition, extensive injury-related data, such as injury severity score (ISS), new injury severity score (NISS), and probability of survival (PS) were collected.

Results

39% had multiple trauma, 34% had multiple injuries including spinal cord injuries, and 27% had isolated spinal cord injuries. Mean NISS was 31.5 (S.D. 13.7). 6% met diagnostic criteria for posttraumatic stress disorder (PTSD) and 9% met the criteria for subsyndromal PTSD. Injury-related data did not influence the prevalence of posttraumatic stress symptoms, however, some psychosocial variables did have a significant impact.

Conclusions

We found a low incidence of PTSD and subsyndromal PTSD. No significant differences were found between the patients suffering from posttraumatic stress symptoms and the non-symptoms group in relation to injury-related data such as ISS/NISS, PS, or multiple trauma versus spinal cord injury. The most evident risk factors for developing posttraumatic stress symptoms were symptoms of anxiety, female gender and negative attitudes toward emotional expression.     

Pediatric spinal injury: the very young

Maturity of the spine and spine-supporting structures is an important variable distinguishing spinal cord injuries in children from those in adults. Clinical data are presented from 71 children aged 12 years or younger who constituted 2.7% of 2598 spinal cord-injured patients admitted to the authors' institutions from June, 1972, to June, 1986. The 47 children with traumatic spinal cord injury averaged 6.9 years of age and included 20 girls (43%). The etiology of the pediatric injuries differed from that of adult injuries in that falls were the most common causative factor (38%) followed by automobile-related injuries (20%). Ten children (21.3%) had spinal cord injury without radiographic abnormality (SCIWORA), whereas 27 (57%) had evidence of neurological injury. Complete neurological injury was seen in 19% of all traumatic pediatric spinal cord injuries and in 40% of those with SCIWORA. The most frequent level of spinal injury was C-2 (27%, 15 cases) followed by T-10 (13%, seven cases). Upon statistical examination of the data, a subpopulation of children aged 3 years or younger emerged. These very young children had a significant difference in level of injury, requirement for surgical stability, and sex distribution compared to 4- to 12-year-old children.     

Spinal cord injury in the work force

Of 144 patients with spinal cord injury admitted to the Sunnybrook Medical Centre from 1974 to 1979, 25 (24 men) (17.4%) had sustained their injuries at work. The 25 patients ranged in age from 20 to 56 years, with more than half being in their third decade of life. Work-related spinal cord injury was more frequent in the thoracic region than spinal injuries from other causes. The injuries were generally severe, 24% of them being complete cord injuries (i.e., no sensory or motor function below the level of injury). The mean neurologic grade of these patients did not change substantially between the time of admission and discharge. The mortality was 8%. The pattern of spinal cord injury in this series was compared to that in the period 1948 to 1973, when 105 (29.3%) of 358 spinal cord injuries occurred at work, constituting the second most frequent cause of acute spinal cord injury, after traffic accidents. In the current series, only 17.4% sustained their injuries at work. This was the third most common cause of spinal injuries in this period after traffic accidents and sports-recreational injuries. Falls in industry were the most frequent mode of work injury from 1974 to 1979, compared with construction accidents in the earlier period. The number of work-related spinal cord injuries is still too high. Furthermore, the severe neurologic damage suffered and the lack of substantial improvement emphasize the importance of preventive efforts, especially in industry. The fact that work injuries now rank third as a relative cause of spinal injury may indicate an absolute decline in this type of injury, especially among construction workers.     

颈髓损伤气管切开影响因素分析

[目的]探讨颈髓损伤患者气管切开的发生率和危险因素。[方法]收集整理1185例颈髓损伤患者的临床资料，统计气管切开率，通过Logistic回归分析评价年龄、性别、工作性质、受伤原因、颈髓损伤程度、颈髓损伤节段、治疗期间营养状态等因素对于患者气管切开率的影响。统计相关因素各分项下的气管切开率。[结果]99例患者被实施气管切开，气管切开率8．35％。年龄、颈髓损伤程度、颈髓损伤节段、受伤原因等因素与气管切开率相关，其他一些因素与气管切开率无显著相关性。随年龄的增长，颈髓损伤患者气管切开率逐渐增加，〈20岁的患者，无1例实施气管切开，〉60岁的患者气管切开率高达38．7％；随颈髓损伤程度的加重和节段的升高，气管切开率不断增加，ASIA分级D级颈髓损伤患者气管切开率为0．5％，而完全性颈髓损伤患者气管切开率高达19．1％；C7～C4节段的颈髓完全性损伤气管切开率分别为4．3％，22．3％，21．6％和32．7％，而c3和c3以上节段的完全性损伤患者，大部分在实施气管切开之前即发生死亡，故气管切开率并不高。高处坠落所致颈髓损伤患者较其他患者有更高的气管切开率。[结论]颈髓严重损伤、颈髓高位损伤和高龄是颈髓损伤患者气管切开的主要危险因素。高位的（c3和c3以上）颈髓完全性损伤患者应尽早实施气管切开。     

Intramedullary lesion expansion on magnetic resonance imaging in patients with motor complete cervical spinal cord injury

Object The authors performed a study to determine if lesion expansion occurs in humans during the early hours after spinal cord injury (SCI), as has been established in rodent models of SCI, and to identify factors that might predict lesion expansion. Methods The authors studied 42 patients with acute cervical SCI and admission American Spinal Injury Association Impairment Scale Grades A (35 patients) and B (7 patients) in whom 2 consecutive MRI scans were obtained 3-134 hours after trauma. They recorded demographic data, clinical information, Injury Severity Score (ISS), admission MRI-documented spinal canal and cord characteristics, and management strategies. Results The characteristics of the cohort were as follows: male/female ratio 37:5; mean age, 34.6 years; and cause of injury, motor vehicle collision, falls, and sport injuries in 40 of 42 cases. The first MRI study was performed 6.8 ±2.7 hours (mean ± SD) after injury, and the second was performed 54.5 ± 32.3 hours after injury. The rostrocaudal intramedullary length of the lesion on the first MRI scan was 59.2 ± 16.1 mm, whereas its length on the second was 88.5 ± 31.9 mm. The principal factors associated with lesion length on the first MRI study were the time between injury and imaging (p = 0.05) and the time to decompression (p = 0.03). The lesion's rate of rostrocaudal intramedullary expansion in the interval between the first and second MRI was 0.9 ± 0.8 mm/hour. The principal factors associated with the rate of expansion were the maximum spinal cord compression (p = 0.03) and the mechanism of injury (p = 0.05). Conclusions Spinal cord injury in humans is characterized by lesion expansion during the hours following trauma. Lesion expansion has a positive relationship with spinal cord compression and may be mitigated by early surgical decompression. Lesion expansion may be a novel surrogate measure by which to assess therapeutic effects in surgical or drug trials.     

The changing epidemiology of spinal trauma: a 13-year review from a Level I trauma centre

IntroductionSpinal injuries secondary to trauma are a major cause of patient morbidity and a source of significant health care expenditure. Increases in traffic safety standards and improved health care resources may have changed the characteristics and incidence of spinal injury. The purpose of this study was to review a single metropolitan Level I trauma centre's experience to assess the changing characteristics and incidence of traumatic spinal injuries and spinal cord injuries (SCI) over a 13-year period.Patients and methodsA retrospective review of patients admitted to a Level I trauma centre between 1996 and 2008 was performed. Patients with spinal fractures and SCI were identified. Demographics, mechanism of injury, level of spinal injury and Injury Severity Score (ISS) were extracted. The outcomes assessed were the incidence rate of SCI and in-hospital mortality.ResultsOver the 13-year period, 5.8% of all trauma patients suffered spinal fractures, with 21.7% of patients with spinal injuries having SCI. Motor vehicle accidents (MVAs) were responsible for the majority of spinal injuries (32.6%). The mortality rate due to spinal injury decreased significantly over the study period despite a constant mean ISS. The incidence rate of SCI also decreased over the years, which was paralleled by a significant reduction in MVA associated SCI (from 23.5% in 1996 to 14.3% in 2001 to 6.7% in 2008). With increasing age there was an increase in spinal injuries; frequency of blunt SCI; and injuries at multiple spinal levels.ConclusionThis study demonstrated a reduction in mortality attributable to spinal injury. There has been a marked reduction in SCI due to MVAs, which may be related to improvements in motor vehicle safety and traffic regulations. The elderly population was more likely to suffer SCI, especially by blunt injury, and at multiple levels. Underlying reasons may be anatomical, physiological or mechanism related.     

Association of head trauma with cervical spine injury, spinal cord injury, or both

BACKGROUND: Links between cervical spine and/or spinal cord injuries and head trauma have not been reported in detail. METHODS: 188 patients with cervical spine and/or spinal cord injury were divided into two groups, i.e., with upper cervical and mid-lower cervical injury, and compared for head injury. RESULTS: Associated head trauma was investigated in 188 patients with cervical spine and/or spinal cord injuries; 35% had moderate or severe injuries. Brain damage was more frequently observed in patients with upper cervical injury than in those with mid to lower cervical injury. Those patients with upper cervical injury appeared to have an elevated risk of suffering skull base fractures, traumatic subarachnoid hemorrhage, and contusional hemotoma. CONCLUSIONS: Approximately one third of patients with cervical spine and/or spinal cord injuries had moderate or severe head injuries. Brain damage was more frequently associated with upper cervical injury. Those patients with upper cervical injury are at greater risk of suffering from skull base fractures and severe intracranial hematomas than those with mid to lower cervical injury.     

The cause of neurologic deterioration after acute cervical spinal cord injury

STUDY DESIGN: A retrospective review was performed to identify patients at risk for secondary neurologic deterioration after complete cervical spinal cord injury. OBJECTIVE: To examine the causes of early neurologic deterioration in patients with complete spinal cord injury at a regional spinal cord injury center. SUMMARY OF BACKGROUND DATA: After complete spinal cord injury, neurologic deterioration occurs in a subgroup of patients. Despite anecdotal reports, no study has clearly identified the subgroups at highest risks. METHODS: One hundred eighty-two patients with complete spinal cord injury were identified among 1904 consecutive patients with acute spinal trauma evaluated from March 1993 through September 1999. Parameters analyzed included demographics, mechanism of injury, American Spinal Cord Injury Association (ASIA) level on admission and during hospital stay, onset of ascension, blood pressure, hemoglobin, febrile episode, heparin administration, and the timing of operation and traction. Radiographs of patients with ascending complete spinal cord injury were reviewed with attention to fracture type and neurologic and vascular injuries. RESULTS: Twelve of 186 patients with ASIA Grade A (6.0%) complete spinal cord injury had neurologic deterioration during the first 30 days after injury. No patients with penetrating injuries had deterioration. A significant association between death and ascension was observed. The onset of ascension of the injury could be categorized into three discrete temporal subsets. Early deterioration (less than 24 hours) was typically related to traction and immobilization. Delayed deterioration (between 24 hours and 7 days) was associated with sustained hypotension in patients with fracture dislocations. Late deterioration (more than 7 days) was observed in a patient with vertebral artery injuries. CONCLUSION: Delayed neurologic deterioration in complete spinal cord injury (ASIA A) is not rare. Specific causes were identified among discrete temporal subgroups. Management of complete spinal cord injury can be improved with recognition of these temporal patterns and earlier intervention.     

Cervical spine injury in young children: a National Trauma Data Bank review

Background

Blunt cervical spine injury (CSI) is rare in the pediatric population. The objective of this study was to better characterize the incidence and type of CSI in young children (age <3 years) using a large, trauma center-based data set.

Methods

The National Trauma Data Bank (NTDB) was reviewed for the period January 2001 to December 2005 for patients younger than 3 years of age with a blunt CSI (International Classification of Diseases, Ninth Revision, 805×, 806×, 952×). Demographic, injury, and outcome information were reviewed. Data management was performed using SAS (SAS, Cary, NC) and Stata (Stata Corp, College Station, TX). Patients with CSI were compared to patients without CSI of similar age. Means were compared with the Wilcoxon rank sum test, medians were compared with a nonparametric test, and count data were compared with the χ² test, with significance set at <.05.

Results

For the period of review, 95,654 young children (age <3 years) with blunt trauma were identified in the NTDB. The overall population had a median Injury Severity Score (ISS) of 4, and most patients (77.01%) had a Glasgow Coma Score (GCS) of 15. There were 1523 (1.59%) patients with a CSI (spinal cord and/or column), including 366 patients (0.38%) with a spinal cord injury (with or without column injury) and 182 (0.19%) with an isolated spinal cord injury (SCIWORA). The CSI and non-CSI populations did not differ regarding median GCS (15 for both groups), but the CSI population had a significantly higher median ISS (14 vs 4, respectively; P < .001). Compared to patients without CSI, the CSI population was more likely to die in the emergency department (2.04% vs 1.25%; P = .007) or be admitted to the intensive care unit (45.3% vs 16.9%; P < .001). Nearly half of all cervical spine fractures (48%) and more than half of cervical spinal cord injuries (53%) were in the lower cervical spine (C5-7). MVCs were the most common injury mechanism (66%) followed by falls (15%). A CSI was observed in 3.2% of all motor vehicle crashes (MVCs).

Conclusions

In this trauma center population, these findings confirm the infrequency of blunt CSI in the youngest (age <3 years) trauma patients. The frequency of injuries to the lower cervical spine is higher than previously appreciated. MVCs are the most likely injury mechanism for this potentially devastating injury.     

Low falls: an underappreciated mechanism of injury

OBJECTIVE: This is a retrospective study designed to evaluate the pattern and severity of injuries that result from low falls, defined as falls from less than 20 ft, subsequent mortality, and requirements of hospital resources. Our hypothesis is that many of these injuries, even without cardiopulmonary instability, are worthy of trauma center care. METHODS: The records of all patients entered into the hospital trauma registry at an urban Level I trauma center during the years 1991 through 1997 who suffered low falls and who either died after admission or were hospitalized for at least 3 days were reviewed. Patients suffering isolated hip fractures were excluded. One hundred seventy-six patients constituted the study population. This group accounts for about 2% of all admissions for falls at our institution. Patterns of injury were examined. Age, mechanism of injury, Injury Severity Score (ISS), and cardiopulmonary or neurologic instability on admission were documented. Mortality, length of intensive care unit and hospital stays, as well as billed hospital charges, were reviewed. RESULTS: The majority of patients (62%) were younger than 50 years. Sixty patients had ISS >15 and 116 patients had ISS >9. Sixty patients had multisystem injuries requiring specialty care. Head injuries were found in 81 patients (35%), and vertebral fractures or spinal cord injuries were found in 49 patients (22%), including 9 quadriplegics and 5 paraplegics. There were seven patients with intra-abdominal injuries (five spleen and two bowel injuries). There was one patient with a rupture of the thoracic aorta. Seventeen patients had deteriorating neurologic or pulmonary function on arrival, but the majority (90%) were stable. Of the 159 "stable" patients, 48 suffered head injuries, 7 were quadriplegic, and 3 were paraplegic. All intra-abdominal injuries were in this group. Overall, 14 of 176 patients (8%) died. Seven deaths were in patients older than 60 years, and seven deaths were in younger patients (p = 0.04). The majority of deaths (9 of 14) were from head trauma. Care in the intensive care unit was required in 92 of 176 patients. Nine patients had billed charges exceeding $100,000. CONCLUSION: Low falls can cause significant injuries, most commonly to the head and spine. Based on mechanism of injury alone, patients injured in low falls might not be taken to trauma centers. We have found, however, that many of these patients sustain serious multisystem injuries, even though they are stable initially. Although these patients represent only a fraction of those who fall, our study would support adjustment of triage guidelines to recommend transport of such patients, particularly elderly patients, to trauma centers.     

Acute spinal cord injury

Acute spinal cord injuries may arise due to blunt injuries or to penetrating trauma, such as stab or gunshot injuries. The severity of injury is best described in terms of the orthopaedic injury and the sensorimotor pattern of neurological deficit (American Spinal Injury Association category). Advanced Trauma Life Support assessment of all trauma patients includes a thorough neurological examination to identify acute spinal cord injury, the management of which requires discussion with a dedicated spinal injuries unit, and, if appropriate, transfer for specialist care. Spinal injuries centres have multidisciplinary teams that can manage the medical and surgical aspects of patient care together with nursing expertise to avoid decubitus ulceration and other complications of spinal cord injury, and a full rehabilitation team to manage the physical, social, financial, and emotional aspects of rehabilitation. People with medical causes of spinal cord injury (e.g. transverse myelitis) experience many of the same problems as people with traumatic spinal cord injury.     

Head injury in the severely injured: long-term follow-up in 157 patients

Ninety-two patients with head injury in the context of multiple injury were followed up 5 years after injury. Severe disability in this group of patients was nearly always due to brain/spinal cord injury, rather than musculoskeletal injury. A substantial number of patients with mild or moderate head injuries had significant persisting disability 5 years after injury.     

Surgical treatment strategy for multiple injury patients in ICU

Objective: To investigate the surgical treatment for patients with multiple injuries in ICU.Methods: Clinical data of 163 multiple injury patients admitted to ICU of our hospital from January 2006 to January 2009 were retrospectively studied, including 118 males and 45 females, with the mean age of 36.2 years (range, 5-67 years). The injury regions included head and neck (29 cases),face (32 cases), chest (89 cases), abdomen (77 cases), pelvis and limbs (91 cases) and body surface (83 cases). There were 57 cases combined with shock. ISS values varied from 10 to 54, 18.42 on average. Patients received surgical treatments in ICU within respectively 24 hours (10 cases), 24-48 hours (8 cases), 3-7 days (7 cases) and 8-14 days (23 cases).Results: Forthe 163 patients, the duration of ICU stay ranged from 2 to 29 days, with the average value of 7.56 days. Among them, 143 were cured (87.73%), 11 died in the hospital (6.75%) due to severe hemorrhagic shock (6 cases),craniocerebral injury (3 cases) and multiple organ failure (2 cases), and 9 died after voluntarily discharging from hospital (5.52%). The total mortality rate was 12.27%.Conclusions: The damage control principle should be followed when multiple injury patients are resuscitated in ICU. Surgical treatment strategies include actively controlling hemorrhage, treating the previously missed injuries and related wounds or surgical complications and performing planned staging operations.     

Acute spinal cord injury: analysis of epidemiologic factors.

The authors studied the epidemiologic aspects of acute spinal cord injury in 358 patients admitted to the Toronto General and Sunnybrook hospitals between 1948 and 1973. The ages of the patients ranged from 14 to 89 years (median 32 years) and the male:female ratio was 4.5:1. The most frequent causes of injury were traffic accidents (34.4%), accidents at work (29.3%), sports-recreational injuries (15.4%) and falls at home (9.8%). Several epidemiologic factors were identified which are important for developing programs to reduce the frequency of cord injury. In particular young persons should be made more aware of the risks they run as automobile drivers and of the hazards of diving in shallow water, middle-aged workers in the construction industry are at risk of spinal cord injury from falls and elderly farmers are at risk of falling from lofts or being crushed by overturned tractors.     

Descriptive epidemiology of traumatic spinal injury in Japan

Background

Spine injury epidemiology in Japan has not been studied since the 1990s when its incidence was 39.4–40.2 per million and the major cause of injury was motor vehicle crashes. We elucidate the current epidemiological state of spinal injury and spinal injury patients in Japan for the clinicians and public health prevention programs.

Spinal cord injury

The annual incidence of acute spinal cord injury in the UK is 15–40 cases per million. More than half these injuries are the result of road traffic accidents, with falls, industrial accidents, sports or violence making up most of the remainder. Violent injury accounts for only a small percentage of cases in this country. The typical patient is male (male to female ratio is 4:1) and young (peak incidence is at 20–40 years). The initial mechanical trauma leads to injury of the neural elements, this is the primary injury. Blood vessels are damaged, axons disrupted and neural cell membranes broken. The spinal cord swells and is compressed in the spinal canal. Ischaemia occurs when the cord swelling exceeds venous blood pressure. This leads to failure of autoregulation of blood flow. The ischaemia leads to a release of toxins from neural cells triggering a secondary injury. The main goal in the management of spinal cord injuries is to prevent secondary injury.     

Anatomic location of spinal cord injury. Relationship to the cause of injury

In a population based sample, 550 of 619 people with fatal and nonfatal spinal cord injuries were classified according to the cause of injury and according to the anatomic location of the highest spinal cord injury. Motor vehicle occupants accounted for 42% of the people with spinal cord injuries. Sixty percent of those injured had a cervical cord injury, 25% a thoracic cord injury, and 15% a lumbosacral cord injury. The specific anatomic locations most commonly injured were at C1 (12% of all spinal cord injuries), C6 (9%), and L2 (5%). The anatomic site of injury was significantly (P less than 0.001) related to the cause of injury. Thirty-seven percent of the spinal cord injuries from firearms and 97% of those from diving were located in the cervical cord. In contrast, 68% of spinal cord injuries to motor vehicle occupants were cervical; 17% at C1. The distribution of injuries among drivers was similar to that among other occupants.