Emergency Neurological Life Support: Traumatic Spine Injury

AI-based automated detection and stability analysis of traumatic vertebral body fractures on computed tomography

PURPOSE

We developed and tested a neural network for automated detection and stability analysis of vertebral body fractures on computed tomography (CT).

MATERIALS AND METHODS

257 patients who underwent CT were included in this Institutional Review Board (IRB) approved study. 463 fractured and 1883 non-fractured vertebral bodies were included, with 190 fractures unstable. Two readers identified vertebral body fractures and assessed their stability. A combination of a Hierarchical Convolutional Neural Network (hNet) and a fracture Classification Network (fNet) was used to build a neural network for the automated detection and stability analysis of vertebral body fractures on CT. Two final test settings were chosen: one with vertebral body levels C1/2 included and one where they were excluded.

RESULTS

The mean age of the patients was 68 ± 14 years. 140 patients were female. The network showed a slightly higher diagnostic performance when excluding C1/2. Accordingly, the network was able to distinguish fractured and non-fractured vertebral bodies with a sensitivity of 75.8 % and a specificity of 80.3 %. Additionally, the network determined the stability of the vertebral bodies with a sensitivity of 88.4 % and a specificity of 80.3 %. The AUC was 87 % and 91 % for fracture detection and stability analysis, respectively. The sensitivity of our network in indicating the presence of at least one fracture / one unstable fracture within the whole spine achieved values of 78.7 % and 97.2 %, respectively, when excluding C1/2.

CONCLUSION

The developed neural network can automatically detect vertebral body fractures and evaluate their stability concurrently with a high diagnostic performance.

Ventilatory Strategies in Traumatic Cervical Spinal Cord Injury: Controversies and Current Updates

Ventilatory management of patients with traumatic cervical spinal cord injury (CSCI) is a complex and controversial area of critical care medicine. Despite significant advances in our understanding of the pathophysiology of CSCI and the development of novel interventions, there remains a lack of consensus about the optimal approach to ventilatory management in these patients. Some of the key controversies in CSCI ventilatory management include timing of tracheal intubation, non-invasive ventilation versus invasive ventilation, high versus low tidal volume, and early versus late tracheostomy. The objective of this review is to discuss the existing controversies and provide an insight on the current evidence.

Timely intubation with early prediction of respiratory exacerbation in acute traumatic cervical spinal cord injury

Background

Early routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in the context of recent advances in multidisciplinary respiratory management, the absolute indication for intubation in patients with CSCI based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation.

Methods

We performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regression was performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS).

Results

Among 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE 3.5 days (mean) post-injury; 3 (37.5%) of eight patients with motor-complete CSCI above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48–42.72, P = 0.0144) in multivariate analyses.

Conclusion

Timely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00530-3.

Acute Traumatic Spinal Cord Injury

Traumatic spinal cord injury is a common neurologic insult worldwide that can result in severe disability. Early stabilization of the patient's airway, breathing, and circulation as well as cervical and thoracolumbar spinal immobilization is necessary to prevent additional injury and optimize outcomes. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the spinal column can assist with determining the extent of bony and ligamentous injury, which will guide surgical management. With or without surgical intervention, patients with spinal cord injury require intensive care unit management and close observation to monitor for potential complications.

Emergency Management of Traumatic Spinal Cord Injuries

Spinal cord trauma constitutes one of the main causes of mortality and morbidity in young adults around the world, with an estimated 2 to 3 new cases for every 100,000 population. Road traffic accidents, falls from high heights, sports injuries, and violent actions are common causes of spinal cord injuries. There is no “gold standard” for the diagnosis of spinal cord traumatic injuries; however, the rational use of conventional radiologic test, computed tomography scan, and magnetic resonance imaging (MRI) will allow to identify almost all clinically relevant injuries. MRI is recommended according to surgeon’s criteria, who after evaluating the specific characteristics of the injury will determine its usefulness. Therapeutic strategies need to be directed to maintain airway, breathing and circulation, maintenance of mean arterial pressure prevention of hypotension, and assessment of other associated injuries. Intensive treatment must be focused on the prevention and management of ventilatory and cardiovascular abnormalities related to muscle weakness and loss of autonomic innervation.

Risk factors for 14-day rehospitalization following trauma with new traumatic spinal cord injury diagnosis: A 10-year nationwide study in Taiwan

Objectives

Fourteen-day rehospitalization with new traumatic spinal cord injury (tSCI) diagnosis is used as an indicator for the diagnostic quality of the first hospitalization. In this nationwide population-based cohort study, we identified risk factors for this indicator.

Methods

We conducted a nested case–control study by using the data of patients who received a first hospitalization for trauma between 2001 and 2011. The data were retrieved from Taiwan’s National Health Insurance Research Database. Variables including demographic and trauma characteristics were compared between patients diagnosed with tSCI at the first hospitalization and those receiving a 14-day rehospitalization with new tSCI diagnosis.

Results

Of the 23 617 tSCI patients, 997 had 14-day rehospitalization with new tSCI diagnosis (incidence rate, 4.22%). The risk of 14-day rehospitalization with new tSCI diagnosis was significantly lower in patients with severe (injury severity score [ISS] = 16–24; odds ratio [OR], 0.17; 95% confidence interval [CI], 0.13–0.21) and profound (ISS > 24; OR, 0.11; 95% CI, 0.07–0.18) injuries. Interhospital transfer (OR, 8.20; 95% CI, 6.48–10.38) was a significant risk factor, along with injuries at the thoracic (OR, 1.62; 95% CI, 1.21–2.18), lumbar (OR, 1.30; 95% CI, 1.02–1.65), and multiple (OR, 3.23; 95% CI, 1.86–5.61) levels. Brain (OR, 2.82), chest (OR, 2.99), and abdominal (OR, 2.74) injuries were also identified as risk factors. In addition, the risk was higher in patients treated at the orthopedic department (OR, 2.26; 95% CI, 1.78–2.87) and those of other surgical disciplines (OR, 1.89; 95% CI, 1.57–2.28) than in those treated at the neurosurgery department.

Conclusions

Delayed tSCI diagnoses are not uncommon, particularly among trauma patients with ISSs < 16 or those who are transferred from lower-level hospitals. Further validation and implementation of evidence-based decision rules is essential for improving the diagnostic quality of traumatic thoracolumbar SCI.

Airway management and mechanical ventilation in acute brain injury

Patients with acute neurologic disease often develop respiratory failure, the management of which profoundly affects brain physiology and long-term functional outcomes. This chapter reviews airway management and mechanical ventilation of patients with acute brain injury, offering practical strategies to optimize treatment of respiratory failure and minimize secondary brain injury. Specific concerns that are addressed include physiologic changes during intubation and ventilation such as the effects on intracranial pressure and brain perfusion; cervical spine management during endotracheal intubation; the role of tracheostomy; and how ventilation and oxygenation are utilized to minimize ischemia-reperfusion injury and cerebral metabolic distress.

Fibromyalgia and arachnoiditis presented as an acute spinal disorder

BACKGROUND

Adhesive arachnoiditis is a chronic, insidious condition that causes debilitating intractable pain and a range of other neurological problems. Its pathophysiology is not well understood. This manuscript discusses its presentations, which can mimic an acute spinal disorder, its hypothetical pathophysiology, treatment, and its relationship with fibromyalgia.

CASE DESCRIPTION

The authors present a case of a 47-year-old female who presented with clinical features mimicking an acute spinal disorder but later found to have an adhesive arachnoiditis. She was admitted following a trauma with complaints of back pain and paraplegia. On examination, there was marked tenderness over thoracolumbar spine with lower limbs upper motor neuron weakness. An urgent magnetic resonance imaging (MRI) of the spine revealed multiple lesions at her thoracic and lumbar spinal canals, which did not compress the spinal cord. Therefore, conservative management was initiated. Despite on regular therapies, her back and body pain worsened and little improvement in her limbs power was noted. Laminectomy was pursued and found to have spinal cord arachnoiditis. Subsequently, she was operated by other team members for multiple pelvic masses, which later proved to be benign. After gathering all the clinical information obtained at surgery and after taking detailed history inclusive of cognitive functions, diagnosis of an adhesive arachnoiditis syndrome was made. Currently, she is managed by neuropsychologist and pain specialist.

CONCLUSION

This case report highlights the importance of knowing an adhesive arachnoiditis syndrome - a rarely discussed pathology by the neurosurgeon, which discloses a significant relationship between immune and nervous systems.

Efficacy of N-acetylcysteine on neuroclinical, biochemical, and histopathological parameters in experimental spinal cord trauma: comparison with methylprednisolone

BACKGROUND

N-acetylcysteine (NAC) is an antioxidant agent that has been shown to have beneficial effects when treating various diseases. The aim of this study was to investigate the effects of NAC on spinal cord injury in an experimental rat model.

METHODS

A total of 48 adult male wistar albino rats were divided into six groups. Group C included the control rats, group L included the rats that underwent laminectomy, and group T included the rats in which spinal cord trauma was induced by the weight-drop method after laminectomy. Groups M (the methylprednisolone group), N (the NAC group), and MN (the methylprednisolone + NAC group) were the treatment groups. In the fourth group (group M), 30 mg/kg methylprednisolone (MP) was administered as a bolus intraperitoneally (IP), and a standard MP treatmentat a dose of 5.4 mg/kg was applied for 24 h. In the fifth group (group N), only 300 mg/kg NAC was administered as a bolus IP. In the sixth group (group MN), the standard MP treatment and a single 300 mg/kg dose of NAC were administered as a bolus IP. The motor functions of the rats were evaluated on the 1st, 7th, and 14th days using the inclined plane test defined by Rivlin and Tator and the motor scale defined by Gale et al. Spinal cord samples were obtained on the 14th day. The samples were evaluated using pathological and biochemical analysis.

RESULTS

In the neuroclinical assessment, no differences were observed between groups T and M in terms of motor improvement. However, statistically significant differences were observed between group T and groups N and MN (p < 0.001, p = 0.01, respectively). Statistically significant differences were also seen between group M and groups N and MN on the 1st and 7th days (p < 0.017, p < 0.01, respectively). Additionally, when groups N and MN were compared with groups T and M,the pathological and biochemical analyses were found to be statistically different (p < 0.05, p < 0.001, respectively).

CONCLUSION

It was concluded that NAC treatment and the combined NAC + MP treatment may be more useful for healing in rats with experimental spinal cord injury in terms of neuroclinical, pathological, and biochemical results than MP-only therapy.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Clinical applicability of magnetic resonance imaging in acute spinal cord trauma

PURPOSE

To assess the clinical application of magnetic resonance imaging (MRI) in patients with acute spinal cord trauma (SCT) according to the type, extension, and severity of injury and the clinical-radiological correlation.

METHODS

Diagnostic imaging [computed tomography (CT) and MRI] tests of 98 patients with acute SCT were analyzed to assess their clinical diagnostic value. The following radiological findings of SCT were investigated: vertebral compression fractures, bursts and dislocations, posterior element fractures, C1 and C2 lesions, vertebral listhesis, bone swelling, spinal canal compression, disk herniation, extradural hematoma, spinal cord contusions, spinal cord swelling, and posterior ligamentous complex (PLC) injuries.

RESULTS

The radiological findings were better visualized using MRI, except for the posterior elements (p = 0.001), which were better identified with CT. A total of 271 lesions were diagnosed as follows: 217 using MRI, 154 using CT, and 100 (36.9 %) using both MRI and CT. MRI detected 117 more lesions than CT.

CONCLUSION

MRI was significantly superior to CT in the diagnosis of bone swelling, PLC injury, disk herniation, spinal canal compression, spinal cord contusion and swelling present in SCT. MRI detected a larger number of lesions than CT and is highly useful for the diagnosis of soft tissue and intrathecal injuries.