Factors that predict poor outcomes in patients with traumatic vertebral body fractures

Systematic Review of Biopsychosocial Prognostic Factors for Return to Work After Acute Orthopedic Trauma: A 2020 Update

OBJECTIVE

To provide updated evidence on prognostic factors for return to work (RTW) in the early and late phases after acute orthopedic trauma from a biopsychosocial perspective.

METHODS

A systematic review of articles indexed in the MEDLINE, CINAHL, and Embase databases between 2010 and 2020 was performed. The inclusion criteria were cohort studies of employed populations sustaining acute orthopedic trauma with follow-up data on RTW. Biopsychosocial prognostic factors for RTW must be reported in the multiple regression models and divided into early (≤ 6 months) and late phases (> 6 months) postinjury. Two reviewers performed study selection, assessed the risk of bias and quality using the Quality in Prognosis Studies (QUIPS) tool and the Newcastle-Ottawa Scale (NOS), and extracted data independently.

RESULTS

Thirty articles were included with a follow-up period of 1-58 months. Based on the QUIPS tool, 7 studies (23%) were considered to have a low risk of bias, and 21 studies (70%) were considered to have a moderate risk of bias. Based on the NOS, the quality was high in 87% of the included studies. The RTW rates ranged from 22% to 74% in the early phase and from 44% to 94% in the late phase. In the early phase, strong evidence was found for injury severity. In the late phase, strong evidence was found for age, injury severity, level of pain, self-efficacy, educational level, blue-collar work, and compensation status; moderate evidence was found for recovery expectations and physical workload. There was limited or inconsistent evidence for the other factors.

CONCLUSION

Based on the levels of evidence, injury severity should be considered as one of the key barriers to RTW in the early and late phases postinjury. This finding underlines the need for serious injury prevention efforts. Our results also emphasize the multifaceted actions of the biopsychosocial model to facilitate RTW: promoting policies for older injured workers, improving access to medical and rehabilitation facilities, and adapting physical workload. Multiple other factors are likely important but require additional high-quality studies to assess their role in the RTW process.

Clinical long-term consequences of thoraco-lumbar spine fracture and osteosynthesis

OBJECT

Although traumatic spine fractures can be treated by osteosynthesis, their long-term clinical, social, and familial consequences are less known. The aim of this study was to assess these global consequences to a very long-term (at least more than 12 years after the fracture).

METHODS

Two groups, one composed of 30 patients operated for a thoracolumbar fracture by posterior fixation and one with 30 controls (who never had a spinal fracture) matched for age, sex, job and time of follow-up were studied. Patients and control subjects had to answer to 3 questionnaires: one about clinical, familial, and socio-professional changes, and 2 back pain (Dallas and Eifel) scales.

RESULTS

The mean patient follow-up was 14.5 years (from 12 to 18 years, sd 2.3) - control subjects, 15 years. The majority (56%) of the fractures occurred at T12/L1 level. At last follow-up, the chronic low back pain concerned 20 (66,7%) patients versus 11 (36.7%) control subjects (p=0.03); more patients (13 patients - 43.3%) consumed analgesics than control (5 persons - 16.6%) subjects (p=0.04). A large majority (13 patients, 57%) had sick leaves that exceeded 6 months. The loss of wage due to traumatism or chronic low back pain was also significant (p=0.002) between patients and matched controls over the period. At follow-up, the mean Eifel score for the whole patients' cohort was significaty superior compared to control group (4.7 [sd 3.75] vs. 2.6 [sd 4.2], p=0.008). Dallas score was superior in the patient's group for the daily, work-leisure activities and sociability aspect (p<0.05).

CONCLUSION

Chronic back pain, long sick leaves, changes in professional and familial life, the very long-term postoperative outcome of patients could be more difficult than expected in a majority of patients operated for thoracolumbar fracture. In order to facilitate the back to work and reduce these long-term consequences, we propose that guidelines about job resume in traumatic spinal fractures should be established along with early occupational medicine consultations.

LEVEL OF EVIDENCE

III; retrospective case control study.

The association between type of spine fracture and the mechanism of trauma: A useful tool for identifying mechanism of trauma on legal medicine field

BACKGROUND

Determining the association between mechanism of trauma, and the type of spine column fracture is a useful approach for exactly describing spine injury on forensic medicine field. We aimed to determine mechanism of trauma based on distribution of the transition of spinal column fractures.

METHODS

This cross-sectional survey was performed on 117 consecutive patients with the history of spinal trauma who were admitted to emergency ward of Rasoul-e-Akram Hospital in Tehran, Iran from April 2015 to March 2016. The baseline characteristics were collected by reviewing the hospital recorded files.

RESULTS

With respect to mechanism of fracture, 63.2% of fractures were caused by falling, 30.8% by collisions with motor vehicles, and others caused by the violence. Regarding site of fracture, lumbosacral was affected in 47.9%, thoracic in 29.9%, and cervical in 13.7%. Regarding type of fracture, burst fracture was the most common type (71.8%) followed by compressive fracture (14.5%). The site of fracture was specifically associated with the mechanism of injury; the most common injuries induced by falling from height were found in lumbosacral and cervical sites, and the most frequent injuries by traffic accidents were found in thoracic site; also the injuries following violence were observed more in lumbar vertebrae. The burst fractures were more revealed in the patients affected by falling from height and by traffic accidents, and both burst and compressive fractures were more observed with the same result in the patients injured with violence (p = 0.003).

CONCLUSION

The type of spine fracture due to trauma is closely associated with the mechanism of trauma that can be helpful in legal medicine to identify the mechanism of trauma in affected patients.

Chronic Pain Following Motor Vehicle Collision: A Systematic Review of Outcomes Associated With Seeking or Receiving Compensation

OBJECTIVE

Motor vehicle collisions (MVC) are a major cause of injury, which frequently lead to chronic pain and prolonged disability. Several studies have found that seeking or receiving financial compensation following MVC leads to poorer recovery and worse pain. We evaluated the evidence for the relationship between compensation and chronic pain following MVC within a biopsychosocial framework.

METHOD

A comprehensive search of 5 computerized databases was conducted. Methodological quality was evaluated independently by 2 researchers according to formal criteria, and discrepancies were resolved with a third reviewer.

RESULTS

We identified 5619 studies, from which 230 full-text articles were retrieved and 27 studies were retained for appraisal. A third of studies (37%) were of low quality, and 44% did not measure or control for factors such as injury severity or preinjury pain and disability. Most studies (70%) reported adverse outcomes, including all of the highest quality studies. Engagement with compensation systems was related to more prevalent self-reported chronic pain, mental health disorders, and reduced return to work. Recovery was poorer when fault was attributed to another, or when a lawyer was involved. Five studies compared Tort "common law" and No-Fault schemes directly and concluded that Tort claimants had poorer recovery.

CONCLUSIONS

Although causal relationships cannot be assumed, the findings imply that aspects of loss, injustice, and secondary mental health outcomes lead to chronic pain following MVC. Further robust prospective research is required to understand the complex relationship between compensation systems and pain following road trauma, particularly the role of secondary mental health outcomes.

RETURN TO WORK AFTER SPINAL FRACTURE SURGERY: AN ANALYSIS OF PREDICTIVE FACTORS

ABSTRACT Objective: To retrospectively evaluate factors that influence the return to work of patients of economically active age submitted to surgery due to spinal fractures. Methods: Patients aged between 18 and 65 years that underwent surgery after spinal fracture from 2012 to 2014 were selected. Through a specific questionnaire and review of the medical records, we identified factors that may have influenced the labor return of these patients. Results: Initially, 114 patients were allocated. After applying the inclusion criteria, 51 patients remained. Age, schooling, time to sit on the bed, and residual pain were the factors that influenced all outcomes. Other variables such as ISS (Injury Severity Score), segment of spine, number of affected vertebrae, associated lesions, and previous employment regimen had no influence. Conclusions: The rate of return to work after being submitted to surgery due to a fracture of the spine is related to age, schooling, residual pain, length of hospital stay, and the time the patient takes to be able to sit alone postoperatively. Physiotherapy positively influences the patient’s self-assessment regarding the ability to perform basic tasks. These variables can be used to identify a possible difficulty in the reallocation of these patients in the labor market.

Predictors of seeking financial compensation following motor vehicle trauma: inception cohort with moderate to severe musculoskeletal injuries

BACKGROUND

Compensation related factors have been repeatedly associated with poor recovery following orthopaedic trauma. There is limited research into the factors associated with seeking financial compensation. Further understanding of these factors could facilitate injury recovery by purposeful compensation scheme design. The aim of this study was to investigate the predictors of seeking financial compensation, namely making a claim and seeking legal representation, following motor vehicle related orthopaedic trauma. The study was conducted in New South Wales (NSW), Australia, in motor vehicle crash and workers' compensation schemes.

METHODS

Participants were patients admitted with upper or lower extremity factures following a motor vehicle crash to two trauma hospitals. Data were collected at baseline within two weeks of injury. Participants were followed up at six months. Analysis involved: descriptive statistics for baseline characteristics; comparison of compensable and non-compensable participants with Analysis of Variance (ANOVA) and chi-squared tests; and logistic regression for predictor models.

RESULTS

The cohort consisted of 452 participants with a mean age 40 years; 75% male; 74% working pre-injury; 30% in excellent pre-injury health; 56% sustained serious injuries with an Injury Severity Score (ISS) 9-15; 61% had a low-middle range household income; and 35% self-reported at fault in the crash. There was no significant difference in pre-injury/baseline health between compensable and non-compensable participants. Follow up data was available for 301 (67%) participants. The significant predictor of claiming compensation in the adjusted analysis was higher body mass index (BMI) (overweight Odds Ratio [OR] 3.05, 95% Confidence Interval [CI] 1.63-5.68; obese OR 1.63, 95% CI 0.83-3.20). Participants less likely to claim were: involved in a motorcycle crash (OR 0.47, 95% CI 0.28-0.82); socioeconomically less disadvantaged (OR 0.37, 95% CI 0.17-0.82) or least disadvantaged (OR 0.39, 95% CI 0.17-0.90); at risk for short term harm (injury) due to alcohol consumption (OR 0.56, 95% CI 0.32-0.97); and with fair-poor pre-injury health (OR 0.30, 95% CI 0.09-0.94). The predictors for seeking legal representation were speaking a language other than English at home (OR 2.80, 95% CI 1.2-6.52) and lower household income (OR 3.63, 95% CI 1.22-10.72). Participants less likely to seek legal representation were least socioeconomically disadvantaged (OR 0.15, 95% CI 0.04-0.50).

CONCLUSIONS

Seeking financial compensation was associated with a higher pre-injury BMI rather than injury-related factors. Seeking legal representation was solely related to socio-economic factors.

The association between seeking financial compensation and injury recovery following motor vehicle related orthopaedic trauma

BACKGROUND

Motor vehicle related moderate-severe orthopaedic trauma has a major impact on the burden of injury. In Australia, all states and territories provide access to financial compensation following injury in a motor vehicle crash. The aim of this study was to investigate the influence of seeking financial compensation (i.e., making a claim) on injury recovery following motor vehicle related moderate-severe orthopaedic trauma.

METHODS

Patients admitted with upper/lower extremity fractures after a motor vehicle crash were recruited from two trauma hospitals. Baseline data were collected in person by written questionnaire within two weeks of injury. Follow up data were collected by a mailed written questionnaire at six, 12 and 24 months. Additional (demographic/injury-related) information was collected from hospital databases, all other measures were self-reported. Outcomes were: Short Form-36 Version 2.0 (SF36v2), Physical/Mental Component Scores (PCS/MCS); Post Traumatic Stress Disorder (PTSD) Checklist Civilian Version (PCL-C); and Global Rating of Change (GRC) scale. Analysis involved descriptive statistics and linear mixed models to examine the effect of compensation status on injury recovery over time.

RESULTS

There were 452 study participants. Baseline characteristics showed: mean age 40 years (17.1 Standard Deviation [SD]); 75 % male; 74 % worked pre-injury; 67 % in excellent-very good pre-injury health; 56 % sustained serious injuries, Injury Severity Score (ISS) 9-15; 61 % had a low-middle range household income. Overall, after controlling for possible confounders, the compensable group had poorer recovery compared to the non-compensable group for PCS (-2.97 Mean Difference (MD), 95 % CI -4.73, -1.22); MCS (-3.44 MD, 95 % CI -5.62, -1.26); PCL-C (3.42MD, 95 % CI 0.87, 5.99); and GRC (-0.66MD, 95 % CI -1.15, -0.17). Injury recovery over time for all participants showed: PCS improved from 6-12 and 12-24 months; MCS and GRC improved from 6-12 months; and PCL-C did not significantly improve from 6-12 and 12-24 months. Injury recovery over time continued for compensable and non-compensable groups but compensable participants had poorer scores at each time period, especially MCS and PCL-C.

CONCLUSIONS

Making a claim was associated with poor injury recovery following motor vehicle related orthopaedic trauma, mainly for mental health. Irrespective of claim status, the majority had poor injury recovery, especially for mental health.

Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain

Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the previous 12 months. We examined: 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared with baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, whereas Veterans Affairs service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes.

PERSPECTIVE

This study identified factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We found that older veterans frequently show improvements in pain intensity over time, and that opioid prescriptions, mental health, and certain pain diagnoses are associated with lower likelihood of improvement.

The effect of financial compensation on health outcomes following musculoskeletal injury: systematic review

The effect of financial compensation on health outcomes following musculoskeletal injury requires further exploration because results to date are varied and controversial. This systematic review identifies compensation related factors associated with poorer health outcomes following musculoskeletal injury. Searches were conducted using electronic medical journal databases (Medline, CINAHL, Embase, Informit, Web of Science) for prospective studies published up to October 2012. Selection criteria included: prognostic factors associated with validated health outcomes; six or more months follow up; and multivariate statistical analysis. Studies solely measuring return to work outcomes were excluded. Twenty nine articles were synthesised and then assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to determine evidence levels. The results were mixed. There was strong evidence of an association between compensation status and poorer psychological function; and legal representation and poorer physical function. There was moderate evidence of an association between compensation status and poorer physical function; and legal representation and poorer psychological function. There was limited evidence of an association between compensation status and increased pain. In seven studies the association depended on the outcome measured. No studies reported an association between compensation related factors and improved health outcomes. Further research is needed to find plausible reasons why compensation related factors are associated with poorer health following musculoskeletal injury.

How well do we report on compensation systems in studies of return to work: a systematic review

PURPOSE

Occupational injury and work-related disability is a significant public health problem. For published research to provide a collective knowledge base for return to work (RTW) policy and practice, features of the compensation system relevant to the research must be described clearly. The level of the reporting on compensation system features is yet to be established. The aim of the present study was to synthesize the evidence for the reporting on compensation systems in prognostic studies of RTW following work-related injuries.

METHODS

A systematic review of the literature was conducted. Ovid Medline and EMBASE were searched for studies published 1996-2011. Included studies were prognostic studies of RTW or work disability following work-related acute traumatic injuries.

RESULTS

The initial search yielded 952 articles; 37 articles fulfilled the inclusion criteria. The majority of studies were based on clinical practice; eight studies were based on administrative data. Only two studies reported seven or more compensation features and two studies reported four to six. The majority of studies (19/37) did not report on any aspect of the compensation system that study participants were interacting with. The most common information reported was the extent of coverage at the population level (7/37) and the availability of wage replacement entitlements (7/37). The name of the compensation system was provided in 5 studies.

CONCLUSIONS

Overall reporting on compensation systems in prognostic studies of RTW needs to be improved if research evidence is to inform policy and practice. Compensation system features that could be reported are provided.

The association between motor vehicle injuries and health-related quality of life: a longitudinal study of a population-based sample in the United States

PURPOSE

As many as 3 million US residents are injured in traffic-related incidents every year leaving many victims with disabling conditions. To date, limited numbers of studies have examined the effects of traffic-related injuries on self-reported health. This study aims to examine the association between health-related quality of life (HRQOL) and traffic-related injuries longitudinally in a nationally representative sample of US adult population.

METHODS/APPROACH

This is a longitudinal study of adult participants (age ≥18) from seven panels (2000-2007) of the Medical Expenditure Panel Survey. The dependent variables included the physical and mental components of the SF-12, a measure of self-reported health. The outcome was assessed twice during the follow-up period: round 2 (~4-5 months into the study) and round 4 (~18 months into the study) for 62,298 individuals. Two methods estimate the association between traffic-related injuries and HRQOL: a within person change using paired tests and a between person change using multivariable regression adjusting for age, sex, income and educational level.

RESULTS

Nine hundred and ninety-three participants reported traffic-related injuries during the follow-up period. Compared to their pre-crash HRQOL, these participants lost 2.7 of the physical component score while their mental component did not change. Adjusted results showed significant deficits in the physical component (-2.84, p value = <.001) but not the mental component (-0.07, p value = .83) of HRQOL after controlling for potential confounders.

CONCLUSION

Traffic injuries were significantly associated with the physical component of HRQOL. These findings highlight the individual and societal burden associated with motor vehicle crash-related disability in the United States.

Advances made in the treatment of thoracolumbar fractures: current trends and future directions

Thoracolumbar fractures are common injuries after blunt trauma and are accompanied with significant morbidity, including neurologic deficit. Parallel to the evolution of initial management during the past few years, efforts have been concentrated on determining clear indications for surgical treatment, as there is no agreement over superiority of conservative or operative treatment. Various classification systems have been used for identifying those injuries requiring surgical intervention. Moreover, novel trends in surgical techniques, including minimal invasive surgery, implants and rehabilitation protocols have provided new, promising aspects regarding the treatment and outcomes of thoracolumbar fractures. The present review focuses on these recent advances.

Outcomes at 12 months after early magnetic resonance imaging in acute trauma patients with persistent midline cervical tenderness and negative computed tomography

STUDY DESIGN

A prospective observational cohort study of alert, neurologically intact trauma patients presenting to the emergency department with midline cervical tenderness. Screening cervical magnetic resonance imaging (MRI) had been conducted after negative computed tomography (CT) when tenderness was persistent.

OBJECTIVE

To determine the association of acute findings and demographic characteristics with any long-term neck disability, and with time to return to work in such patients.

SUMMARY OF BACKGROUND DATA

The relationship between acute findings and outcomes in these patients is unknown, and we hypothesized that outcomes at 12 months would correlate with acute clinical signs and symptoms, MRI findings, and mechanisms of injury.

METHODS

Patients at a Level 1 trauma center with persistent midline cervical tenderness in the absence of evidence of intoxication, painful distracting injury, persistently abnormal neurology, or acute CT findings, who underwent early cervical MRI under the institutional protocol, were reviewed in the outpatient spine clinic after discharge. In addition, the factors associated with neck disability and time to return to work were examined at follow-up at 12 months after presentation.

RESULTS

There were 162 of 178 patients available for follow-up at 12 months (91%). Of these, 46% had MRI-identified cervical spine injury at their initial examination, and 22% had required clinical management, including 2.5% with operative stabilization. Neck disability was present in 43% of patients and was associated with depressive symptoms, workers' compensation, and low annual income. Delay in return to work was associated with the presence of minor limb/other fractures and depressive symptoms, whereas patients on high annual incomes were found to return to work more quickly.

CONCLUSION

Surprisingly in these acute trauma patients, MRI-detected injury, clinical factors, and injury mechanism were not found to be associated with long-term patient outcomes. As a result, a trial of a more targeted, individual return to work plan, including strategies aimed at improving physical and psychological function, may now be justified to optimize long-term recovery, reduce health resource costs, and maximize economic productivity through early return to work.

Do compensation processes impair mental health? A meta-analysis

BACKGROUND

Victims who are involved in a compensation processes generally have more health complaints compared to victims who are not involved in a compensation process. Previous research regarding the effect of compensation processes has concentrated on the effect on physical health. This meta-analysis focuses on the effect of compensation processes on mental health.

METHOD

Prospective cohort studies addressing compensation and mental health after traffic accidents, occupational accidents or medical errors were identified using PubMed, EMBASE, PsycInfo, CINAHL, and the Cochrane Library. Relevant studies published between January 1966 and 10 June 2011 were selected for inclusion.

RESULTS

Ten studies were included. The first finding was that the compensation group already had higher mental health complaints at baseline compared to the non-compensation group (standardised mean difference (SMD)=-0.38; 95% confidence interval (CI) -0.66 to -0.10; p=.01). The second finding was that mental health between baseline and post measurement improved less in the compensation group compared to the non-compensation group (SMD=-0.35; 95% CI -0.70 to -0.01; p=.05). However, the quality of evidence was limited, mainly because of low quality study design and heterogeneity.

DISCUSSION

Being involved in a compensation process is associated with higher mental health complaints but three-quarters of the difference appeared to be already present at baseline. The findings of this study should be interpreted with caution because of the limited quality of evidence. The difference at baseline may be explained by a selection bias or more anger and blame about the accident in the compensation group. The difference between baseline and follow-up may be explained by secondary gain and secondary victimisation. Future research should involve assessment of exposure to compensation processes, should analyse and correct for baseline differences, and could examine the effect of time, compensation scheme design, and claim settlement on (mental) health.