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Background
Spinal immobilization has been a standard procedure in out-of-hospital treatment of trauma patients for decades. There are increasing reports in the current literature about complications of spinal immobilization. Thus, the use of decision aids for the indication of spinal immobilization is recommended. The application of most existing immobilization protocols is limited to some extent. To our knowledge, an immobilization protocol, applicable for all adult trauma patients that permits variable decision-making depending on the current condition of the trauma patient and the pattern of injuries is currently not available.Objectives
The aim of the current study was to develop a protocol as a decision aid for preclinical spinal immobilization of adult trauma patients and to perform a preliminary test of applicability by German medical students via a questionnaire.Materials and methods
A structured literature search for publications concerning spinal immobilization was performed. Afterwards, the Emergency Medicine Spinal Immobilization Protocol (E.M.S. IMMO Protocol) for adult trauma patients, basing on the current literature and guidelines, was developed. A preliminary test of applicability was performed with 86 German medical students by means of a questionnaire.Results
A new protocol for preclinical spinal immobilization could be provided and visualized. Questions that analyze the correct application and understanding of the E.M.S. IMMO Protocol were predominantly answered correctly by German medical students. The main reasons for incorrect answers were evaluated in a direct feedback session and were not found to be directly related with the E.M.S. IMMO Protocol but with a lack of experience in emergency medicine.Conclusions
The E.M.S. IMMO Protocol provides a decision aid for the indication for out-of-hospital spinal immobilization in adult trauma patients that permits variable decision-making depending on the current condition of the trauma patient and the pattern of injuries for immobilization in general and for immobilization methods in particular.3.
Manuel Ribeiro da Silva Daniela Linhares Pedro Cacho Rodrigues Eurico Lisboa Monteiro Manuel Santos Carvalho Pedro Negrão Rui Peixoto Pinto Nuno Neves 《International orthopaedics》2016,40(6):1111-1116
Purpose
This observational study aims to describe pediatric C-spine injuries from a level 1 trauma centre through a period of 19 years.Methods
Clinical records of pediatric trauma patients admitted to a level 1 trauma centre between 1991 and 2009 were analyzed. Patients were stratified by age into groups A (8 or less) and B (9 to 16), and in lower (C0-C2) and upper (C3-C7) spine injuries. Several variables were studied.Results
Seventy-five cases of C-spine injuries (nine SCIWORA) were identified. Group A included 23 patients and group B 52. In group A, skeletal injuries at the upper C-spine were more common than injuries at the lower C-spine, whereas in group B, injuries of the lower C-spine were more frequent (p?=?0.035). Motor vehicle accidents were the main cause of injury (44 %); 25.3 % of patients were surgically treated. Thirty-nine patients presented neurologic deficits, 16 of which improved. The overall mortality rate was 18.7 % and significantly higher in patients with neurological damages (p?<?0.001)Conclusions
This study revealed a low incidence of cervical spine injuries in the paediatric population. As in previous reports younger children mainly sustained injuries at the upper C-spine, higher incidence of spinal injuries, and higher risk of death than older children.4.
Purpose
The objective of this study was to analyze the interobserver reliability and intraobserver reproducibility of the new AOSpine thoracolumbar spine injury classification system in young Chinese orthopedic surgeons with different levels of experience in spinal trauma. Previous reports suggest that the new AOSpine thoracolumbar spine injury classification system demonstrates acceptable interobserver reliability and intraobserver reproducibility. However, there are few studies in Asia, especially in China.Methods
The AOSpine thoracolumbar spine injury classification system was applied to 109 patients with acute, traumatic thoracolumbar spinal injuries by two groups of spinal surgeons with different levels of clinical experience. The Kappa coefficient was used to determine interobserver reliability and intraobserver reproducibility.Results
The overall Kappa coefficient for all cases was 0.362, which represents fair reliability. The Kappa statistic was 0.385 for A-type injuries and 0.292 for B-type injuries, which represents fair reliability, and 0.552 for C-type injuries, which represents moderate reliability. The Kappa coefficient for intraobserver reproducibility was 0.442 for A-type injuries, 0.485 for B-type injuries, and 0.412 for C-type injuries. These values represent moderate reproducibility for all injury types. The raters in Group A provided significantly better interobserver reliability than Group B (P < 0.05). There were no between-group differences in intraobserver reproducibility.Conclusions
This study suggests that the new AO spine injury classification system may be applied in day-to-day clinical practice in China following extensive training of healthcare providers. Further prospective studies in different healthcare providers and clinical settings are essential for validation of this classification system and to assess its utility.5.
Christopher K. Kepler Alexander R. Vaccaro John D. Koerner Marcel F. Dvorak Frank Kandziora Shanmuganathan Rajasekaran Bizhan Aarabi Luiz R. Vialle Michael G. Fehlings Gregory D. Schroeder Maximilian Reinhold Klaus John Schnake Carlo Bellabarba F. Cumhur Öner 《European spine journal》2016,25(4):1082-1086
Purpose
The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably.Methods
A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ).Results
The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility.Conclusion
In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.6.
Purpose
Noncontiguous double-level unstable spinal injuries (NDUSI) are uncommon and have not been well described. In this study, we aimed to better understand the patterns of NDUSI, in order to recommend proper diagnostic and treatment methods, as well as to raise awareness among traumatologists about the possibility of these uncommon injuries.Methods
A total of 710 consecutive patients with spine fractures were treated for >9 years since 2007 at a single regional trauma center. Of them, 18 patients with NDUSI were reviewed retrospectively.Results
The incidence of NDUSI was 2.5 % of all spine fractures. In 17 of 18 patients (94.7 %), NDUSI was caused by a high-energy trauma. Nine patients (50.0 %) exhibited complete neurological deficit. Spinal cord injury occurred in the cranial injured region in all American Spinal Injury Association grade A cases. In one case, a second fracture was overlooked at the initial examination.Conclusion
NDUSI are common in cases of high-energy trauma and should be taken into consideration at the initial examination. A second fracture may be easily overlooked because of the high frequency of concomitant severe spinal cord injury in the cranial injured region and/or loss of consciousness due to associated injuries. To avoid overlooking injuries, full spine computed tomography is useful at the initial examination. Operative reduction and internal fixation with instrumentation through a posterior approach is recommendable for cases of NDUSI. In elderly patients, a very rapid stabilizing surgery should be planned before aspiration pneumonia occurs or the pulmonary condition worsens.7.
Background and objectives
The question about the need of spinal immobilization of trauma patients in general, and the various ways to do it in particular are nowadays increasingly discussed in scientific literature. Furthermore, daily practice of spinal immobilization routines also reflects a huge heterogeneity. The aim of this article is to give an overview about exemplarily selected literature on the subject of spinal immobilization of trauma patients. Thus, possible recommendations concerning spinal immobilization could be derived by the reader.Spinal immobilization of trauma patients
The general lack of evidence towards spinal immobilization is well known. In the current scientific literature increasing hints can be found that the sole application of a cervical collar does not ensure a sufficient immobilization of the cervical spine. Thus, total spine immobilization, meaning fixation of the entire body of the trauma patient is recommended. However, total spine immobilization is also said to be associated with significant complications such as aggravated airway management or reduced lung function due to restrictions. Furthermore, the application of a cervical collar can lead to increased intracranial pressure. Thus, the indication for spinal immobilization should be sophisticated on behalf of immobilization decision tools such as the Canadian C-spine rule. In patients with acute life threatening conditions such as Hemorrhagic shock, it must be decided whether the immediate transport can be delayed by immobilization procedures. In the case of a trauma patient suffering from severe traumatic brain injury, one should consider whether the application of a cervical collar is mandatory or if alternative ways of immobilization could be carried out. Hence, the vacuum mattress offers better stability and greater comfort during total spinal immobilization compared to the spine board.8.
Introduction
Injuries to the cervical spine are immanently accompanied by trauma to the extracranial cerebral arteries.Material and methods
A prospective cohort study was carried out from October 2013 to October 2015 including 76 patients (39 women and 37 men) with a median age of 77 years and either fractures or discoligamentary injuries who were examined with duplex sonography and/or computed tomography (CT) angiography. Additionally, approximately 80 patients with a cervical spine distorsion were evaluated using the same modalities. Statistical analyses were carried out using the program Bias 11.01.Results
The overall incidence of traumatic dissection of the internal carotid artery was 2.5?% and in 50?% of the cases (1.2?%) with neurological symptoms. For vertebral arteries the incidence of 10.5?% was relatively high and 25?% of patients were symptomatic (2.6?%). Osteophytes and the degree of displacement were identified as the major risk factors. The vertebral canal and the skull base were regions most prone to vascular injury. In the case of distorsion of the cervical spine no vascular trauma has so far been found.Conclusion
In cases of trauma to the cervical spine accompanying vascular injuries should also be taken into consideration. The current therapy option is anticoagulation in cases of neurologically asymptomatic patients. Patients with neurological symptoms could benefit from endovascular techniques.9.
Algorithm for activation of coagulation support treatment in multiple injured patients––cohort study
Background
Early recognition and management of trauma related coagulopathy improves the outcome. Trauma facilities should implement an algorithm to identify the bleeding trauma patient with coagulopathy.Objective
The scope of the paper is to identify the indicators of early coagulopathy and to optimize the indications for thromboelastometry and coagulation support.Design
Cohort study based on data from trauma registry.Setting
Data of 493 major trauma patients treated in GH Celje from 2006 to 2014 were included into The TraumaRegister DGU® (TR-DGU).Patients
Patients were selected for inclusion into TR-DGU according to the following criteria: polytraumatized patients with Injury severity score (ISS) ≥ 18, patients with injuries to single region with AIS 5, patients with major injuries to a single region and abnormal vital signs. All patients that were dead on arrival to hospital, patients presented to hospital >24 h after the injury, and head injuries that occurred with a low energy mechanism in patients on anticoagulation drugs were excluded.Measurements
Two groups were formed (with or without coagulopathy). Mortality, morbidity, length of mechanical ventilation, ICU and hospital stay were used as outcome and compared between the groups. A coagulopathy prediction model (CPM) was developed to identify the patients who were at high risk of coagulopathy.Results
Coagulopathy was present in 51 % of patients. Severe injuries to the torso and limbs, infusion of >1000 ml of fluids in the prehospital settings, and hypotension were included into CPM. If all three criteria were present, the sensitivity of the model to predict coagulopathy was 93 %. By adding the blood gas analysis (BE ≤ ?5), the specificity increased to 81.7 %.Limitations
Shortcomings of our analysis are mainly related to the quality of data in the registry that may not be comparable to a clinical trial where data are collected specifically to address a given issue.Conclusions
The Criteria for activation of coagulation support treatment remain centre dependent. In our settings the CPM is the tool to select patients for ROTEM® analysis. By adding data from blood gas analysis, treatment of coagulopathy is justifiable before complete test results are available.10.
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Background
Caring for pediatric spine trauma patients places spine surgeons in situations that require unique solutions for complex problems. Recent case reports have highlighted a specific injury pattern to the lower cervical spine in very young children that is frequently associated with complete spinal cord injury.Methods
This report describes the presentation and treatment of a C6–C7 dislocation in a 3-year-old patient with an incomplete spinal cord injury. The highly unstable cervical injury and the need to prevent neurologic decline added complexity to the case.Results
A multi-surgeon team allowed for ample manpower to position the patient; with individuals with the requisite training and experience to safely move a patient with a highly unstable cervical spine. Initial closed reduction under close neurophysiologic monitoring, posterior fusion and immediate anterior stabilization lead to a successful patient outcome with preserved neurologic function. A traumatic cerebrospinal fluid leak, while a concern early on during the procedure, resolved without direct dural repair and did not complicate the patient’s fusion healing. Additional anterior stabilization and fusion allowed long-term stability with bone healing that may not be achievable with posterior fixation and/or soft tissue healing alone.Conclusions
Familiarity with the challenges and solutions presented in the case may be useful to surgeons who could face a similar challenge in the future.12.
Introduction
Establishing a definitive airway in order to ensure adequate ventilation and oxygenation is an important aspect of resuscitation of the polytrauma patient .Aim
To review the relevant literature that compares the different drugs used for rapid sequence intubation (RSI) of trauma patients, specifically reviewing: premedication, induction agents and neuromuscular blocking agents across the prehospital, emergency department and operating room setting, and to present the best practices based on the reviewed evidence.Method
A literature review of rapid sequence intubation in the trauma population was carried out, specifically comparison of the drugs used (induction agent, neuromuscular blocking drugs and adjuncts).Discussion
Studies involving the comparison of drugs used in RSI in, specifically, the trauma patient are sparse. The majority of studies have compared induction agents, etomidate, ketamine and propofol, as well as the neuromuscular blocking agents, succinylcholine and rocuronium.Conclusion
There currently exists great variation in the practice of RSI; however, in trauma the RSI armamentarium is limited to agents that maintain hemodynamic stability, provide adequate intubating conditions in the shortest time period and do not have detrimental effects on cerebral perfusion pressure. Further, multicenter randomized controlled studies to confirm the benefits of the currently used agents in trauma are required.13.
Introduction
Trauma is a large contributor to morbidity and mortality in developing countries. We sought to determine which anatomic injury locations and mechanisms of injury predispose to prehospital mortality in Malawi to help target preventive and therapeutic interventions. We hypothesized that head injury would result in the highest prehospital mortality.Methods
This was a retrospective analysis of all trauma patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from 2008 to 2015. Independent variables included baseline characteristics, anatomic location of primary injury, mechanism of injury, and severity of secondary injuries. Multivariable logistic regression was used to assess the effect of primary injury location and injury mechanism on prehospital death, after adjusting for confounders. Effect measure modification of the primary injury site/prehospital death relationship by injury mechanism (stratified into intentional and unintentional injury) was assessed.Results
Of 85,806 patients, 701 died in transit (0.8%). Five hundred and five (72%) of these patients sustained a primary head injury. After adjustment, head injury was the anatomic location most associated with prehospital death (OR 11.81 (95% CI 6.96–20.06, p?<?0.0001). The mechanisms of injury most associated with prehospital death were gunshot wounds (OR 38.23, 95% CI 17.66–87.78, p?<?0.0001) and pedestrian hit by vehicle (OR 2.62, 95% CI 1.92–3.55, p?<?0.0001). Among head injury patients, the odds of prehospital mortality were higher with unintentional injuries.Conclusions
Head injuries are the most common causes of prehospital death in Malawi, while pedestrians hit by vehicles are the most common mechanisms. In a resource-poor setting, preventive measures are critical in averting mortality.14.
Purpose
Primary spinal osteosarcoma is quite rare, and the 5-year survival rate is very low. Because of its rarity, successful treatment experience with spinal osteosarcoma is limited. The purpose of this study is to report the effect of therapy of primary osteosarcoma of spine by carbon-ion radiotherapy (CIRT) and long-term follow.Methods
A 70-year-old with primary spinal osteosarcoma who received CIRT underwent combined anterior artificial vertebral body replacement and posterior lumbar fusion (L1–L5) 3 years later.Results
According to the surgical resection of tumoral lesion, pathological results showed that the intertrabecular space previously filled with tumor cells on the initial biopsy sample now contained necrotic tissue without tumor cells. This means that primary osteosarcoma of the spine was completely eliminated and achieved local control with CIRT, with a 7-year follow-up after the initial treatment.Conclusions
Carbon ion beam treatment is an effective local treatment for patients with spinal osteosarcoma for whom surgical resection is not a feasible option, especially for elderly patients. However, more patients need to be evaluated over a longer term to assess the curative effect of CIRT.15.
Introduction
With a survey among Dutch orthopedic surgeons, we try to assess whether eponymous terms are still in use in daily practice. We also tried to find out whether younger generations tend to use them less than our older colleagues.Materials and methods
In a survey consisting of 57 eponymous terms, 67 participants were asked to mark the eponyms they knew and whether they used them in daily practice.Results
No correlation was observed in known/used eponyms or years of experience in 58 completed surveys. Respondents who classified themselves as trauma or general orthopedic surgeons knew or used a significantly higher number of eponyms in daily practice than orthopedic surgeons who classified themselves as spine, upper limb, lower limb, sports or pediatric surgeons.Discussion
Eponymous terms are used frequently in daily practice. Super-specialization might eradicate the general orthopedic surgeon, and the number of eponyms known and used might become smaller and more focused on the super-specialty.Conclusion
Our survey showed that eponymous terms are still used frequently in daily practice among both young and more senior orthopedic surgeons in The Netherlands.16.
Alexander R. Vaccaro Gregory D. Schroeder Christopher K. Kepler F. Cumhur Oner Luiz R. Vialle Frank Kandziora John D. Koerner Mark F. Kurd Max Reinhold Klaus J. Schnake Jens Chapman Bizhan Aarabi Michael G. Fehlings Marcel F. Dvorak 《European spine journal》2016,25(4):1087-1094
Purpose
The goal of the current study is to establish a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system.Methods
A survey was sent to AOSpine members from the six AO regions of the world, and surgeons were asked if a patient should undergo an initial trial of conservative management or if surgical management was warranted. The survey consisted of controversial injury patterns. Using the results of the survey, a surgical algorithm was developed.Results
The AOSpine Trauma Knowledge forum defined that the injuries in which less than 30 % of surgeons would recommend surgical intervention should undergo a trial of non-operative care, and injuries in which 70 % of surgeons would recommend surgery should undergo surgical intervention. Using these thresholds, it was determined that injuries with a thoracolumbar AOSpine injury score (TL AOSIS) of three or less should undergo a trial of conservative treatment, and injuries with a TL AOSIS of more than five should undergo surgical intervention. Operative or non-operative treatment is acceptable for injuries with a TL AOSIS of four or five.Conclusion
The current algorithm uses a meaningful injury classification and worldwide surgeon input to determine the initial treatment recommendation for thoracolumbar injuries. This allows for a globally accepted surgical algorithm for the treatment of thoracolumbar trauma.17.
Purpose
The purpose of this study was to develop a simple and clinically useful morphological classification system for congenital lumbar spinal stenosis using sagittal MRI, allowing clinicians to recognize patterns of lumbar congenital stenosis quickly and be able to screen these patients for tandem cervical stenosis.Methods
Forty-four subjects with an MRI of both the cervical and lumbar spine were included. On the lumbar spine MRI, the sagittal canal morphology was classified as one of three types: Type I normal, Type II partially narrow, Type III globally narrow. For the cervical spine, the Torg-Pavlov ratio on X-ray and the cervical spinal canal width on MRI were measured. Kruskal–Wallis analysis was done to determine if there was a relationship between the sagittal morphology of the lumbar spinal canal and the presence of cervical spinal stenosis.Results
Subjects with a type III globally narrow lumbar spinal canal had a significantly lower cervical Torg-Pavlov ratio and smaller cervical spinal canal width than those with a type I normal lumbar spinal canal.Conclusion
A type III lumbar spinal canal is a globally narrow canal characterized by a lack of spinal fluid around the conus. This was defined as “functional lumbar spinal stenosis” and is associated with an increased incidence of tandem cervical spinal stenosis.18.
Masanari Takami Amr Elwany Jean Destandau 《European journal of orthopaedic surgery & traumatology : orthopedie traumatologie》2016,26(3):253-258
Background
Although many reports are available on using a variety of instruments and techniques to prevent wrong-level spine surgery, the accurate localization of the correct spinal level remains problematic. At the same time, surgeons are also required to reduce radiation exposure to patients and operating room personnel. To solve these problems, we developed and used specially designed marking devices with a unique three-dimensional structure.Purpose
To evaluate the accuracy of our novel devices for localization of the spinal level to prevent wrong-level surgery and reduce the amount and time of radiation exposure during surgery.Study design
This was a retrospective cohort study.Methods
In 8240 consecutive patients who underwent microendoscopic spine surgery between 1993 and 2012, the incidence of wrong-level surgery was studied. In addition, the amount of radiation exposure and total fluoroscopy time were measured in recent 100 consecutive patients using a digital dosimeter attached to the fluoroscope.Results
Eight (0.097 %) patients had undergone wrong-level surgery. The average radiation exposure was 0.26 mGy (range 0.10–1.15 mGy), and the average total fluoroscopy time was 3.1 s (range 1–7 s).Conclusions
Our novel localization devices and technique for their use in spine surgery are reliable and accurate for identifying the target level and contributed to reductions in preoperative localization error and radiation exposure to patients and operating room personnel.19.
Hanish Kataria Robin Kaushik Simrandeep Singh Rajeev Sharma 《Hellēnikē cheirourgikē. Acta chirurgica Hellenica》2017,89(2):121-125
Background
Although blunt abdominal trauma is frequently encountered, isolated duodenal injury is relatively uncommon. The management of such patients is challenging and various surgical procedures are described for their management.Methods
Two patients presented to our emergency department with isolated duodenal injuries (transection and devascularisation) secondary to blunt abdominal trauma.Results
Both patients underwent exploratory laparotomy, revealing transection of the duodenum along with proximal devascularization and detachment of mesentery at duodeno-jejunal junction without any other intra-abdominal injury (especially pancreas, colon, vena cava) for which pancreas-sparing duodenectomy (infra-ampullary) was performed.Conclusion
Pancreas-sparing duodenectomy is a valuable tool in the management of duodenal trauma, allowing the surgeon (and the patient) to avoid the complications of major surgical resections.20.