Risk factors predicting mortality after blunt traumatic cervical fracture

Cervical Fracture During COVID-19 Pandemic Era: A Case Series

Background

Cervical fractures are potentially serious and can have fatal consequences if not treated properly. Correct diagnosis and classification of injury is the first step in determining the most appropriate treatment. Cervical fractures will have an impact on the patient’s work, and COVID-19 is a challenge in the hospital to treat a cervical fracture. This study aims to discuss the case of patients with cervical fractures that have undergone surgical treatment in the COVID-19 pandemic.

Case Presentation

Two cases of emergency patients with cervical injury treated at the hospital in the acute setting of the COVID-19 pandemic. All these patients experienced delayed timing to arrive in the emergency department of Prof. Dr. R. Soeharso Orthopedic Hospital. Neurological outcome was assessed before being discharged after surgery and a 3-month follow-up post-surgery.

Results

Laminectomy and posterior stabilization and fusion (PSF) were performed immediately after diagnosis was established in both patients. Physical rehabilitation was performed. In a 3-month follow-up, both patients’ neurological functions improved.

Conclusion

Clinical outcomes of cervical injury patients can be affected by some factors, for example, timing to diagnosis, timing to traction application, timing to surgery, and timing to rehabilitation. Depending on the institution, weekend days can also affect the delay of the COVID-19 PCR swab. MRI schedule and patient optimal condition can also affect the timing to surgery. The immediate diagnosis and prompt treatment are needed to make a better outcome, especially better neurological status.

Predicting survival in older patients treated for cervical spine fractures: development of a clinical survival score

BACKGROUND CONTEXT

Emerging literature has identified the importance of pretreatment health and functional status as influential in the prognostication of survival. A comprehensive, accessible, predictive model for survival following cervical spine fracture has yet to be developed.

PURPOSE

To develop an accessible and intuitive predictive model for survival in individuals aged 50 and older treated for cervical spine fractures.

STUDY DESIGN

Retrospective review of records from two tertiary care centers (2009-2016).

PATIENT SAMPLE

Patients age 50 and older who received operative or nonoperative management for cervical fractures.

OUTCOME MEASURES

One-year mortality was the primary outcome with 3-month and 2-year mortality considered secondarily.

METHODS

Multivariable logistic regression was used to identify factors independently associated with mortality. The magnitude and precision of the relationship with 1-year mortality for statistically significant variables determined weighting in the scoring system subsequently developed. Score performance was tested through multivariable regression and bootstrap simulation. In a sensitivity test, the performance of the score developed for 1-year mortality was assessed using figures for the 3-month and 2-year time-points.

RESULTS

We included 1,758 patients. Mortality rates were 12% at 3 months, 17% at 1 year, and 21% at 2 years. Following multivariable testing age, injury severity score and Glasgow coma scale demonstrated the strongest predictive values for a base score, followed by serum albumin and ambulatory status. The resultant composite score ranged from 0 (base score≤4, albumin≤3.5 g/dL, and dependent/nonambulator at presentation) to a maximum of 4 (base score≥5, albumin>3.5 g/dL, and independent ambulator at presentation). Following multivariable analysis, when compared to patients with a score of 4, significantly increased odds of 1-year mortality were appreciated for those with scores of 3 (odds ratio [OR] 7.35; 95% confidence interval [CI] 3.77, 14.32), 2 (OR 8.43; 95% CI 4.66, 15.25), 1 (OR 17.47; 95% CI 9.81, 31.11), and 0 (OR 26.58; 95% CI 13.87, 50.92). Score performance was unchanged in bootstrap testing and sensitivity analyses.

CONCLUSIONS

We have developed a useful prognostic utility capable of informing survival in individuals age 50 and older, following cervical spine fractures. The score can be applied to adjust patient expectations, anticipate outcomes, and as an adjunct to decision-making in the postinjury period.

Incidence of traumatic cervical spine fractures in the Norwegian population: a national registry study

BACKGROUND

The incidence of cervical spine fractures (CS-fx) in the general population is sparingly assessed. The aim of the current study was to estimate the incidence of traumatic CS-fx and of open surgery of cervical spine injuries in the Norwegian population.

METHODS

The Norwegian Patient Register (NPR) is an administrative database that contains activity data from all Norwegian government-owned hospitals and outpatient clinics. The diagnoses and procedures are coded according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and the NOMESCO Classification of Surgical Procedures (NCSP), respectively. We retrieved information on all severe traumatic cervical spine injuries between 2009 and 2012 from the NPR. Updated information on the date of death is included through routine linkage to the General Register Office.

RESULTS

Between 2009 and 2012, a total of 3 248 patients met our criteria for severe traumatic cervical spine injury. A total of 2 963 patients had one or more CS-fx, and 285 had severe non-fracture cervical spine injuries. The median age was 54 years, and 69% of the patients were male. The incidence of CS-fx and severe non-fracture injuries in the total Norwegian population was 16.5/100 000/year, and the incidence of CS-fx was 15.0/100 000/year. A total of 18% of the patients were treated with open surgery, resulting in an estimated incidence of surgery for acute traumatic cervical spine injury of 3.0/100 000/ year in the Norwegian population. The 1- and 3-month mortality rates were 4% and 6%, respectively.

Patient demographics, insurance status, race, and ethnicity as predictors of morbidity and mortality after spine trauma: a study using the National Trauma Data Bank

BACKGROUND CONTEXT

Predictors of complications and mortality after spine trauma are underexplored. At present, no study exists capable of predicting the impact of demographic factors, injury-specific predictors, race, ethnicity, and insurance status on morbidity and mortality after spine trauma.

PURPOSE

This study endeavored to describe the impact of patient demographics, comorbidities, injury-specific factors, race/ethnicity, and insurance status on outcomes after spinal trauma using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB).

STUDY DESIGN

The weighted sample of 75,351 incidents of spine trauma in the NTDB was used to develop a predictive model for important factors associated with mortality, postinjury complications, length of hospital stay, intensive care unit (ICU) days, and time on a ventilator.

PATIENT SAMPLE

A weighted sample of 75,351 incidents of spine trauma as contained in the NTDB.

OUTCOME MEASURES

Mortality, postinjury complications, length of hospital stay, ICU days, and time on a ventilator as reported in the NTDB.

METHODS

The 2008 NSP of the NTDB was queried to identify patients sustaining spine trauma. Patient demographics, race/ethnicity, insurance status, comorbidities, injury-specific factors, and outcomes were recorded, and a national estimate model was derived. Unadjusted differences in baseline characteristics between racial/ethnic groups and insurance status were evaluated using the t test for continuous variables and Wald chi-square analysis for categorical variables with Bonferroni correction for multiple comparisons. Weighted logistic regression was performed for categorical variables (mortality and risk of one or more complications), and weighted multiple linear regression analysis was used for continuous variables (length of hospital stay, ICU days, and ventilator time). Initial determinations were checked against a sensitivity analysis using imputed data.

RESULTS

The weighted sample contained 75,351 incidents of spine trauma. The average age was 45.8 years. Sixty-four percent of the population was male, 9% was black/African American, 38% possessed private/commercial insurance, and 12.5% lacked insurance. The mortality rate was 6% and 16% sustained complications. Increased age, male gender, Injury Severity Score (ISS), and blood pressure at presentation were significant predictors of mortality, whereas age, male gender, other mechanism of injury, ISS, and blood pressure at presentation influenced the risk of one or more complications. Nonwhite and black/African American race increased risk of mortality, and lack of insurance increased mortality and decreased the number of hospital days, ICU days, and ventilator time.

CONCLUSIONS

This is the first study to postulate predictors of morbidity and mortality after spinal trauma in a national model. Race/ethnicity and insurance status appear to be associated with greater risk of mortality after spine trauma.

Predictors for mortality in elderly patients with cervical spine injury: a systematic methodological review

STUDY DESIGN

Systematic methodological review.

OBJECTIVE

Identify predictors for cervical spine injury (CSI) mortality in elderly patients by reviewing the available literature.

SUMMARY OF BACKGROUND DATA

The proportion of active elderly individuals in society is increasing. This population is at high risk for CSI mortality. The results of studies identifying predictors for CSI mortality in the elderly population are often inconclusive or even conflicting. Currently, there is no set of predictors that can adequately identify and describe CSI mortality risk for the elderly. Thus, we performed a systematic review to identify the predictors for mortality in elderly patients with CSI.

METHODS

We performed searches in the MEDLINE, EMBASE, ScienceDirect, and OVID databases (articles published prior to May 2012) for noninterventional studies that evaluated predictors for CSI mortality in the elderly. Only those observational studies with eligible data were included. Study quality was assessed using a modified quality assessment tool that was designed previously for an observational study. Study outcomes were combined with study quality scores using a best-evidence synthesis model.

RESULTS

Twenty-three observational studies involving 2325 patients were included. These studies were published between 1993 and 2011. According to the quality assessment criteria, 8 studies were of high quality, 11 studies were of moderate quality, and 4 studies were of low quality. We identified 3 strong evidence predictors for CSI mortality, including pre-existing comorbidities, spinal cord injury, and age. We also identified 3 moderate evidence predictors, 7 limited evidence predictors and 1 conflicting evidence predictor.

CONCLUSION

Although there is no conclusive evidence regarding the mortality of elderly patients with CSI, these data provide information that can help us to make recommendations and to counsel patients and their families. Special attention should be paid to the 3 strong predictors. Further studies will be required to validate these predictors.

The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway

Aim

The aim of this study was to estimate the incidence of traumatic cervical spine fractures (CS-fx) in a general population.

Background

The incidence of CS-fx in the general population is largely unknown.

Methods

All CS-fx (C0/C1 to C7/Th1) patients diagnosed with cervical-CT in Southeast Norway (2.7 million inhabitants) during the time period from April 27, 2010-April 26, 2011 were prospectively registered in this observational cohort study.

Results

Over a one-year period, 319 patients with CS-fx at one or more levels were registered, constituting an estimated incidence of 11.8/100,000/year. The median age of the patients was 56 years (range 4–101 years), and 68% were males. The relative incidence of CS-fx increased significantly with age. The trauma mechanisms were falls in 60%, motorized vehicle accidents in 21%, bicycling in 8%, diving in 4% and others in 7% of patients. Neurological status was normal in 79%, 5% had a radiculopathy, 8% had an incomplete spinal cord injury (SCI), 2% had a complete SCI, and neurological function could not be determined in 6%. The mortality rates after 1 and 3 months were 7 and 9%, respectively. Among 319 patients, 26.6% were treated with open surgery, 68.7% were treated with external immobilization with a stiff collar and 4.7% were considered stable and not in need of any specific treatment. The estimated incidence of surgically treated CS-fx in our population was 3.1/100,000/year.

Conclusions

This study estimates the incidence of traumatic CS-fx in a general Norwegian population to be 11.8/100,000/year. A male predominance was observed and the incidence increased with increasing age. Falls were the most common trauma mechanism, and SCI was observed in 10%. The 1- and 3-month mortality rates were 7 and 9%, respectively. The incidence of open surgery for the fixation of CS-fx in this population was 3.1/100,000/year.

Level of evidence

This is a prospective observational cohort study and level II-2 according to US Preventive Services Task Force.

Prehospital transport of patients with spinal cord injury in Nigeria

BACKGROUND

A well-organized and efficient prehospital transport is associated with improved outcome in trauma patients. In Nigeria, there is paucity of information on prehospital transport of patients with spinal cord injury (SCI) and its relation to mortality.

OBJECTIVE

To determine if prehospital transportation is a predictor of mortality in patients with SCI in Nigeria.

DESIGN

Prospective cohort study

METHODS

Prehospital transport related conditions, injury arrival intervals and persons that brought patients with SCI to the casualty were noted. Data analyzed using descriptive statistics, the chi-square test and multiple logistic regressions.

MAIN OUTCOME MEASURES

Mortality within 6 weeks on admission

RESULTS

168 patients with SCI presented in the casualty during this review period. Majority (67.9%) presented after 24 hrs of the injury. Majority (58.3%) were conveyed into the casualty by their relatives. Salon car (54.2%) was the most common mode of transportation where majority (55.4%) laid on their back during the transfer. Majority (75%) of the patients had multiple hospital presentation before reporting in our casualty. The mortality observed was 16.7%. Multivariate analysis after adjusting for age, gender, and means of transportation revealed that age (OR= 63.41, 95% CI= 9.24-43.53), crouched position during transfer (OR= 23.52, 95% CI= 7.26-74.53), presentation after 24 hrs (OR=5.48, 95% CI=3.20-16.42) and multiple hospital presentation (OR= 7.94, 95% CI= 1.89-33.43) were associated with mortality within 6 weeks of admission.

CONCLUSION

A well-organized and efficient prehospital transport would reduce mortality in spinal cord injured patients. Public enlightenment campaign on factors that could reduce road traffic injury would help reduce mortality.

Fracture characteristics predict patient mortality after blunt force cervical trauma

Fractures of the cervical spine after blunt cervical trauma are associated with high rates of patient mortality. The purpose of this study was to investigate patient and fracture characteristics that predict mortality. This is a retrospective, case cohort study of all adult patients admitted to our institution between January 1998 and June 2008 with cervical fracture after blunt cervical trauma (N=218). All patient records were reviewed. The patient and fracture characteristics and outcome data were stored. Age (P=0.002), involvement of the fourth cervical vertebra (P=0.002), lamina fracture (P=0.001), and a facet fracture (P=0.006) were identified as independent significant risk factors for mortality. In conclusion, mortality is highly affected by patient age, but fracture location and fracture pattern are also predictive of poor patient outcome. Fracture patterns may increase the risk of spinal cord injury at a level that can affect but not eliminate neural control of the diaphragm, which have the worst prognosis for patient mortality.