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Chen ZD, Tu CQ, Jiang YJ, Zeng YZ, Huang ZZ, Cai TY, Lin B. Management of non-contiguous upper and lower cervical spine fractures. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06308-z. [PMID: 39242395 DOI: 10.1007/s00264-024-06308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/28/2024] [Indexed: 09/09/2024]
Abstract
PURPOSE Upper cervical fracture combined with non-contiguous lower cervical fracture are not uncommon but complicated. In order to outline a management principle for the upper cervical fracture combined with non-contiguous lower cervical fracture and assess its clinical characteristics, we retrospectively analyzed 59 cases of patients who underwent surgical treatment for upper cervical fracture combined with non-contiguous lower cervical fracture. METHODS 59 patients of upper cervical fracture combined with non-contiguous lower cervical fracture were treated by surgery in our hospital. According to the AO Spine classification for cervical fractures, there were 21 cases of type B atlas fractures, nine cases of type C atlas fractures; 15 cases of type B axis fractures, 14 cases of type C axis fractures; 19 cases of type B lower cervical fractures, 40 cases of type C lower cervical fractures. The operation time, intraoperative blood loss, complications, VAS scores, JOA scores, ASIA grades, and radiological evaluation of cervical lordosis and stability were collected and recorded. RESULTS Our results showed the segments of upper cervical fracture combined with non-contiguous lower cervical fracture are mainly concentrated in the atlas-axis and C6, C7 levels. There were 43 cases (72.88%) of associated injuries, mainly involving head trauma and thoracic injuries. Four patients underwent anterior approach surgery only, 43 patients underwent posterior approach surgery only, and 12 patients underwent combined anterior and posterior approach surgery in one stage. All patients had regular follow up with an average duration of 67.83 ± 11.25 months (range, 39 to 103 months). The VAS scores and JOA scores at 12 months postoperatively and at final follow-up showed significant improvement compared to preoperative scores (P < 0.05). At the final follow-up, ASIA grades had improved by 0 to 2 levels. The cervical lordosis at the final follow-up (24.71°±7.39°) showed no statistically significant difference compared to preoperative measurements (26.89°±13.32°). Surgical complications occurred in 17 patients. No cases of vertebral artery injury, screw loosening, or other internal fixation failures were found at final follow-up. CONCLUSIONS Upper cervical fracture combined with non-contiguous lower cervical fracture can result in varying extents of cervical spinal cord injury and combined trauma in other parts. Surgical treatment of these injuries can achieve favourable clinical and radiological outcomes in the medium to long term follow-up. More research is still needed to optimize clinical decision-making regarding surgical approach.
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Affiliation(s)
- Zhi-da Chen
- Department of Orthopaedics, The 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, 363000, China
| | - Cheng-Quan Tu
- Department of Orthopaedics, The 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, 363000, China
| | - Yuan-Jie Jiang
- Department of Orthopaedics, The 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, 363000, China
| | - Yu-Zhe Zeng
- Department of Orthopaedics, The 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, 363000, China
| | - Zhuan-Zhi Huang
- Department of Orthopaedics, The 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, 363000, China
| | - Tao-Yi Cai
- Department of Orthopaedics, The 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, 363000, China.
| | - Bin Lin
- Department of Orthopaedics, The 909th Hospital, School of Medicine, Xiamen University, Zhangzhou, 363000, China.
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Li S, Xu X, Chang M, Li H, Xu R, Fu W, Wang L, Li Y, Yuan S, Tian Y, Wang L, Liu X. The establishment of a novel upper cervical complex fracture classification system. Spine J 2024:S1529-9430(24)00929-X. [PMID: 39154938 DOI: 10.1016/j.spinee.2024.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 08/11/2024] [Accepted: 08/11/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND CONTEXT Upper cervical complex fractures are associated with high rates of neurological damage and mortality. The Dickman's classification is widely used in the diagnosis of upper cervical complex fractures. However, it falls short of covering the full spectrum of complex fractures. This limitation hinders effective diagnosis and treatment of these injuries. PURPOSE To address the diagnostic gap in upper cervical complex fractures, the study introduces a novel classification system for these injuries, assessing its reliability and usability. STUDY DESIGN Proposal of a new classification system for upper cervical complex fractures. PATIENT SAMPLE The study comprised the clinical data of 242 patients with upper cervical complex fractures, including 32 patients treated at our hospital, along with an additional 210 cases from the literature. OUTCOME MEASURES The inter-observer and intra-observer reliability (kappa coefficient, κ) of this classification system were investigated by 3 spine surgeons. The 3 researchers independently re-evaluated the upper cervical complex fracture classification system 3 months later. METHODS The proposed classification categorizes upper cervical complex fractures into 3 main types: Type I combines odontoid and Hangman's fractures into 2 subtypes; Type II merges C1 with odontoid/Hangman's fractures into 3 subtypes; and Type III encompasses a combination of C1, odontoid, and Hangman's fractures, divided into 2 subtypes. Meanwhile, a questionnaire was administered in 15 assessors to evaluate the system's ease of use and clinical applicability. RESULTS A total of 45 cases (18.6%) unclassifiable by Dickman's classification were successfully categorized using our system. The mean κ value of inter-observer reliability was 0.783, indicating substantial reliability. The mean κ value of intra-observer reliability was 0.862, indicating almost perfect reliability. Meanwhile, thirteen assessors (87.7%) stated that the classification system is easy to remember, easy to apply, and they expressed intentions to apply it in clinical practice in the future. CONCLUSIONS This system not only offers high confidence and reproducibility but also serves as a precise guide for clinicians in formulating treatment plans. Future prospective applications are warranted to further evaluate this classification system.
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Affiliation(s)
- Shangye Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Xiulian Xu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Mingzheng Chang
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Hao Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Rongkun Xu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Wenyang Fu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Lulu Wang
- Department of Orthopedics, Shengli Oilfield Central Hospital, Dongying, Shandong, P.R. China
| | - Yonggang Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Suomao Yuan
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Yonghao Tian
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Lianlei Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Xinyu Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China.
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Bunmaprasert T, Chaiamporn A, Laohapoonrungsee A, Liawrungrueang W, Chunjai K, Atthakomol P. A system of predictive scores to evaluate the risk of multilevel noncontiguous spinal fractures in patients with traumatic cervical spine injury. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2340-2346. [PMID: 38709275 DOI: 10.1007/s00586-024-08277-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/07/2024] [Accepted: 04/15/2024] [Indexed: 05/07/2024]
Abstract
PURPOSE To develop a predictive scoring system to identify traumatic cervical spine injury patients at a high risk of having multilevel noncontiguous spinal fractures. METHODS This 12-year retrospective observational cohort study included 588 traumatic cervical spine-injured patients. Patients were categorized into two groups: patients with multilevel noncontiguous spinal fractures and patients without this remote injury. Potential risk factors were examined using multivariable analysis to derive a predictive risk score from independent predictors. Results are presented as odds ratio with a 95% confidence interval (95% CI). The accuracy of the calculated predicted score was demonstrated by the area under the receiver operating characteristic curve (AuROC). RESULTS The incidence of noncontiguous fracture among the patients was 17% (100 of 588). The independent risk factors associated with multilevel noncontiguous spinal fractures were motor weakness, intracranial injury, intrathoracic injury, and intraabdominal injury. The AuROC of the prediction score was 0.74 (95% CI 0.69, 0.80). The patients were classified into three groups, low-risk group (score< 1), moderate-risk group (score 1-2.5), and high-risk group (score≥ 3), based on the predicted risk of multilevel noncontiguous spinal fractures. CONCLUSIONS This tool can potentially help preventing the missed diagnosis of cervical spine injuries with multilevel noncontiguous spinal fractures. CT scans or MRI of the entire spine to investigate remote multilevel noncontiguous spinal fractures may have a role in cervical spine-injured patients who have at least one of the independent risk factors and are strongly suggested for patients with scores in the high-risk group.
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Affiliation(s)
- Torphong Bunmaprasert
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, 110 Intrawarorot Road Soi 2, Si Phum, Amphoe Mueang Chiang Mai, Chiang Mai, 50200, Thailand
| | - Anuchit Chaiamporn
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, 110 Intrawarorot Road Soi 2, Si Phum, Amphoe Mueang Chiang Mai, Chiang Mai, 50200, Thailand
| | - Anupong Laohapoonrungsee
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, 110 Intrawarorot Road Soi 2, Si Phum, Amphoe Mueang Chiang Mai, Chiang Mai, 50200, Thailand
| | | | - Kanlaya Chunjai
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, 110 Intrawarorot Road Soi 2, Si Phum, Amphoe Mueang Chiang Mai, Chiang Mai, 50200, Thailand
| | - Pichitchai Atthakomol
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, 110 Intrawarorot Road Soi 2, Si Phum, Amphoe Mueang Chiang Mai, Chiang Mai, 50200, Thailand.
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Pirillo V, Berti PP, Prontera A, Rizzo P, Broger M. Biomechanics considerations in the treatment of double traumatic non-contiguous subaxial cervical lesions. Br J Neurosurg 2023; 37:1781-1785. [PMID: 33792457 DOI: 10.1080/02688697.2021.1907309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
Double traumatic non-contiguous lesions of the subaxial cervical region are a rare event mostly caused by multiple, simultaneous or rapidly consecutive high-energy-impact traumas. The modality of treatment chosen for these lesions must be related to local lower cervical spine biomechanics. We present the case of a 59 year-old patient who suffered a subaxial cervical spine double fracture-dislocation following a complex-dynamic trauma. Radiological imaging displayed a C4-C5 and C7-T1 fracture-dislocation with cord signal intensity abnormalities. This patient showed a complete neurological deficit (ASIA A; mJOA 0) with a C4 sensory-motor level. He was urgently operated upon through an anterior approach, reduction of both dislocations and positioning of intervertebral cages and anterior plates at C4-C5 and C7-T1. At a 16-month follow-up he displays neurological improvement, moving his upper extremities at the C7-C8 motor level and a T5 sensory level (mJOA 3; Odom's Criteria 3). The check-CT scan at 24-month shows the correct positioning of the stabilization system and a complete bone fusion.Double traumatic lesions of the subaxial cervical spine, when interposed by healthy functional segments can be treated as two single independent lesions in order to allow a better outcome.
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Affiliation(s)
- Vania Pirillo
- Department of Neurosurgery, S. Maurizio Hospital, Bolzano, Italy
| | - Pier Paolo Berti
- Department of Neurosurgery, Civile Maggiore Hospital, University of Verona, Verona, Italy
| | - Andrea Prontera
- Department of Neurosurgery, S. Maurizio Hospital, Bolzano, Italy
| | - Paolo Rizzo
- Department of Neurosurgery, S. Maurizio Hospital, Bolzano, Italy
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Tang A, Gambhir N, Menken LG, Shah JK, D'Ambrosio M, Ramakrishnan V, Liporace FA, Yoon RS. Identification of concomitant injuries associated with specific spine level fractures in polytrauma patients. Injury 2022; 53:1068-1072. [PMID: 34920875 DOI: 10.1016/j.injury.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/04/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Spine fractures are associated with high energy mechanisms and can lead to substantial morbidity and mortality in the trauma setting. Rapid identification and treatment of these fractures and their associated injuries are paramount in preventing adverse outcomes. The purpose of this study is to identify concomitant skeletal and non-skeletal injuries related to cervical, thoracic, and lumbar fractures. METHODS A retrospective review of institutional American College of Surgeons (ACS) registry was conducted on 3,399 consecutive trauma patients identifying those with spine fractures from 1/2016-12/2019. Two-hundred ninety patients were included(8.5%) and separated into three groups based on fracture location: eighty-eight cervical(C)-spine, 129thoracic(T)-spine, and 143lumbar(L)-spine. Logistic regression analyses were performed to identify associated injuries, presenting injury severity score(ISS) and Glasgow coma scale(GCS), mechanism of injury, demographic data, substance use, and paralysis for each group. Cox hazard regression was utilized to identify factors associated with inpatient mortality. RESULTS C-spine fractures were associated with head trauma(OR2.18,p = 0.003),intracranial bleeding (OR2.64,p = 0.001),facial(OR2.25,p = 0.02) and skull fractures(OR3.92,p = 0.001),and cervical cord injuries(OR4.78,p = 0.012). T-spine fractures were associated with rib fractures(OR2.31,p = 0.003). L-spine fractures were associated with rib(OR1.77, p = 0.04), pelvic(OR5.11,p<0.001), tibia/fibula (OR2.31,p = 0.05), and foot/ankle fractures(OR3.32,p = 0.04), thoracic(OR2.43,p = 0.008) and retroperitoneal cavity visceral injuries(OR27.3,p = 0.001). Falls≤6meters were also significantly associated with C-spine fractures(OR1.70,p = 0.04) while falls>6meters were associated with L-spine fractures(OR4.30,p = 0.001). Inpatient mortality risk increased in patients with C-spine fractures(HR4.41,p = 0.002), higher ISS(HR1.05, p<0.001), and lower GCS(HR0.85,p<0.001). Last, patients≥65-years-old were more likely to experience C-spine fractures(OR1.88,p = 0.03). CONCLUSION Patients who experience fractures of the cervical, thoracic, or lumbar spine are at risk for additional fractures, visceral injury, and/or death. Awareness of the associations between spinal fractures and other injuries can increase diagnostic efficacy, improve patient care, and provide valuable prognostic information. These associations highlight the importance of effective and timely communication and multidisciplinary collaboration.
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Affiliation(s)
- Alex Tang
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, 355 Grand Street, Jersey City, NJ 07302, United States of America
| | - Neil Gambhir
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, 355 Grand Street, Jersey City, NJ 07302, United States of America
| | - Luke G Menken
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, 355 Grand Street, Jersey City, NJ 07302, United States of America
| | - Jay K Shah
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, 355 Grand Street, Jersey City, NJ 07302, United States of America
| | - Matthew D'Ambrosio
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, 355 Grand Street, Jersey City, NJ 07302, United States of America
| | - Vivek Ramakrishnan
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, 355 Grand Street, Jersey City, NJ 07302, United States of America
| | - Frank A Liporace
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, 355 Grand Street, Jersey City, NJ 07302, United States of America
| | - Richard S Yoon
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, 355 Grand Street, Jersey City, NJ 07302, United States of America.
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Spine trauma: Radiological approach and new concepts. Skeletal Radiol 2021; 50:1065-1079. [PMID: 33165712 DOI: 10.1007/s00256-020-03668-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/30/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
The spine is the main stabilizer and load bearer of the axial skeleton. It is also important for the protection of neural structures, such as the spinal cord, nerve roots, and cauda equina. In the healthy skeleton, most injuries are a consequence of high-energy trauma and can lead to severe dysfunction, such as tetraplegia or paraplegia. In order to avoid such disabilities, it is important to recognize details that will guide treatment, and that will determine the necessity or not to have surgery. Familiarity with radiography, CT, and MRI in evaluating spine trauma is necessary, as, in some cases, all three methods will be useful in determining management and surgical planning. The most important factor in determining management in the thoracolumbar spine is the posterior ligamentous complex (PLC). Therefore, familiarity with its anatomy, primary and secondary signs of its injuries, is essential for radiologists in the emergency setting. Spine fractures are a very heterogeneous group of disorders. Management can be both conservative and surgical. It is important for radiologists to be aware of classifications and patterns for these injuries.
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Anandasivam NS, Ondeck NT, Bagi PS, Galivanche AR, Samuel AM, Bohl DD, Grauer JN. Spinal fractures and/or spinal cord injuries are associated with orthopedic and internal organ injuries in proximity to the spinal injury. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 6:100057. [PMID: 35141623 PMCID: PMC8820026 DOI: 10.1016/j.xnsj.2021.100057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/13/2021] [Accepted: 03/17/2021] [Indexed: 11/25/2022]
Abstract
Background the demographics, mechanisms of injury, and concurrent injuries associated with cervical, thoracic and lumbar spinal fracture and/or spinal cord injury remain poorly characterized. Methods Patients aged 18 and older with spinal injury between 2011 and 2015 in the National Trauma Data Bank (NTDB) were identified. Patient demographics, comorbidity burden, mechanism of injury, and associated injuries were analyzed. Results in total, 520,183 patients with acute spinal injury were identified including 216,522 cervical, 191,218 thoracic, and 220,294 lumbar. The age distributions were trimodal with peaks in incidence at around 2155 and a lesser peak around 85 years of age. The number of comorbidities increased while injury severity decreased with advancing patient age. Motor vehicle accidents (MVAs) were the most common mechanism of injury. Associated bony and internal organ injuries were common and occurred in 63% of cervical spine injury patients, 79% of thoracic spine injury patients, and 71% of lumbar spine injury patients. In all three sub-populations, there was a predominance of injuries in the local area of the primary injury. For cervical, these were rib injuries (28%), thoracic spine injuries (22%), skull fractures (20%), intracranial injuries (26%) and lung injuries (21%). For thoracic, these were rib injuries (47%), lumbar spine injuries (26%), cervical spine injuries (25%), lung injuries (35%) and intracranial injuries (24%). For lumbar, these were rib injuries (38%), thoracic spine injuries (22%), pelvic fractures (20%), lung injuries (26%) and intracranial injuries (19%). Multivariate regression analysis demonstrated that increased injury severity was strongly correlated with increased mortality, with lesser contributions from increased age and comorbidity burden. Conclusions the current study revealed spinal fractures and/or cord injuries had high incidences of associated injuries that had a predominance of local distribution. These findings, in combination with the mortality analysis, demonstrate the importance of local targeted evaluations for associated injuries.
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Beckmann NM, West OC, Nunez D, Kirsch CF, Aulino JM, Broder JS, Cassidy RC, Czuczman GJ, Demertzis JL, Johnson MM, Motamedi K, Reitman C, Shah LM, Than K, Ying-Kou Yung E, Beaman FD, Kransdorf MJ, Bykowski J. ACR Appropriateness Criteria® Suspected Spine Trauma. J Am Coll Radiol 2019; 16:S264-S285. [DOI: 10.1016/j.jacr.2019.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
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Alessandrino F, Bono CM, Potter CA, Harris MB, Sodickson AD, Khurana B. Spectrum of diagnostic errors in cervical spine trauma imaging and their clinical significance. Emerg Radiol 2019; 26:409-416. [PMID: 30929146 DOI: 10.1007/s10140-019-01685-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/12/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To describe and categorize diagnostic errors in cervical spine CT (CsCT) interpretation performed for trauma and to assess their clinical significance. METHODS All CsCTs performed for trauma with diagnostic errors that came to our attention based on clinical or imaging follow-up or quality assurance peer review from 2004 to 2017 were included. The number of CsCTs performed at our institution during the same time interval was calculated. Errors were categorized as spinal/extraspinal, involving osseous/soft tissue structures, by anatomical site and level. Images were reviewed by a radiologist and two spine surgeons. For each error, the need for surgery, immobilization, CT angiogram of the neck, and MRI was assessed; if any of these were needed, the error was considered clinically significant. RESULTS Of an approximate total 59,000 CsCTs, 56 reports containing diagnostic errors were included. Twelve were extraspinal, and 44 were spinal (26 fractures, 15 intervertebral disc protrusions, two subluxations, one lytic bone lesion). The most common sites of spinal fractures were vertebral body (n = 10) and transverse process (n = 8); the most common levels were C5 (n = 8) and C7 (n = 6). All (n = 26) fractures and two atlantooccipital subluxations were considered clinically significant, including three patients who would have required urgent surgical stabilization (two subluxations and one facet fracture). Two transverse processes fractures did not alter the need for surgical intervention/surgical approach, immobilization, or MRI. CONCLUSIONS In our study, 66% of spinal diagnostic errors on CsCT were considered clinically significant, potentially altering clinical management. Transverse process and vertebral body fractures were commonly missed.
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Affiliation(s)
- Francesco Alessandrino
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Christopher M Bono
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christopher A Potter
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Aaron D Sodickson
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Bharti Khurana
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Santos-Nunez G, Lo HS, Kotecha H, Jose J, Abayazeed A. Imaging of Spine Fractures With Emphasis on the Craniocervical Junction. Semin Ultrasound CT MR 2018; 39:324-335. [DOI: 10.1053/j.sult.2018.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Occipital Condyle Fractures and Concomitant Cervical Spine Fractures: Implications for Management. World Neurosurg 2018; 115:e238-e243. [DOI: 10.1016/j.wneu.2018.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/03/2018] [Accepted: 04/04/2018] [Indexed: 11/22/2022]
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Liao S, Schneider NRE, Weilbacher F, Stehr A, Matschke S, Grützner PA, Popp E, Kreinest M. Spinal movement and dural sac compression during airway management in a cadaveric model with atlanto-occipital instability. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1295-1302. [DOI: 10.1007/s00586-017-5416-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/11/2017] [Indexed: 12/19/2022]
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Liao S, Popp E, Hüttlin P, Weilbacher F, Münzberg M, Schneider N, Kreinest M. Cadaveric study of movement in the unstable upper cervical spine during emergency management: tracheal intubation and cervical spine immobilisation-a study protocol for a prospective randomised crossover trial. BMJ Open 2017; 7:e015307. [PMID: 28864483 PMCID: PMC5588953 DOI: 10.1136/bmjopen-2016-015307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Emergency management of upper cervical spine injuries often requires cervical spine immobilisation and some critical patients also require airway management. The movement of cervical spine created by tracheal intubation and cervical spine immobilisation can potentially exacerbate cervical spinal cord injury. However, the evidence that previous studies have provided remains unclear, due to lack of a direct measurement technique for dural sac's space during dynamic processes. Our study will use myelography method and a wireless human motion tracker to characterise and compare the change of dural sac's space during tracheal intubations and cervical spine immobilisation in the presence of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture. METHODS AND ANALYSIS Perform laryngoscopy and intubation, video laryngoscope intubation, laryngeal tube insertion, fiberoptic intubation and cervical collar application on cadaveric models of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture. The change of dural sac's space and the motion of unstable cervical segment are recorded by video fluoroscopy with previously performing myelography, which enables us to directly measure dural sac's space. Simultaneously, the whole cervical spine motion is recorded at a wireless human motion tracker. The maximum dural sac compression and the maximum angulation and distraction of the injured segment are measured by reviewing fluoroscopic and myelography images. ETHICS AND DISSEMINATION This study protocol has been approved by the Ethics Committee of the State Medical Association Rhineland-Palatinate, Mainz, Germany. The results will be published in relevant emergency journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER DRKS00010499.
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Affiliation(s)
- Shiyao Liao
- Department of Trauma Surgery and Orthopedics, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Erik Popp
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Petra Hüttlin
- Department of Trauma Surgery and Orthopedics, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Frank Weilbacher
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Münzberg
- Department of Trauma Surgery and Orthopedics, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Niko Schneider
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Kreinest
- Department of Trauma Surgery and Orthopedics, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
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Zhang W, Yu H, Liang C, Jiao W, Cao J, Li C. [Treatment of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:982-986. [PMID: 29806437 PMCID: PMC8458596 DOI: 10.7507/1002-1892.201703113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/10/2017] [Indexed: 11/03/2022]
Abstract
Objective To discuss the clinical characteristics, mechanism, and treatment of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation. Methods According to the inclusion and exclusion criteria, 7 male patients aged 37-71 years (mean, 51.4 years), suffered from odontoid fractures combined with lower cervical spinal cord injuries without fracture or dislocation were analyzed retrospectively between June 2007 and October 2015. The trauma causes were traffic accidents in 2 cases, fall in 2 cases, and hit injury in 3 cases. The time from injury to admission was 2 hours to 3 days with an average of 9 hours. According to Anderson-Grauer classification of odontoid fracture, 1 case of type IIA, 3 cases of type IIB, 2 cases of type IIC, and 1 case of shallow type III were found. The cervical spinal cord injuries affected segments included C 4, 5 in 1 case, C 4-6 in 2 cases, and C 5-7 in 4 cases. All the cervical spine had different degenerative changes: 2 of mild, 3 of moderate, and 2 of severe. The lower cervical spinal cord injury was assessed by Sub-axial Injury Classification (SLIC) with scoring of 4-6 (mean, 5.1). The visual analogue scale (VAS) score was used to evaluate the occipital neck pain with scoring of 7.8±1.0; the neurological function was assessed by American Spinal Injury Association (ASIA) as grade B in 1 case, grade C in 4 cases, and grade D in 2 cases; and Japanese Orthopedic Association score (JOA) was 9.2±3.9. For the odontoid fractures, 4 cases were fixed with anterior screw while the others were fixed with posterior atlantoaxial fixation and fusion. For the lower cervical spine, 4 cases were carried out with anterior cervical corpectomy and titanium fusion while the others with anterior cervical disecotomy and Cage fusion. Results The operation time was 178-252 minutes (mean, 210.2 minutes); the intraoperative blood loss was 60-140 mL (mean, 96.5 mL) and with no blood transfusion. All incisions healed primarily. All the patients were followed up 12-66 months (mean, 18 months). There was no direct surgical related complications during operation, and all bone grafting got a fusion at 6-9 months (mean, 7.7 months) after operation. There was no inter-fixation failure or loosening. At last follow-up, the VAS score declined to 1.7±0.7 and JOA score improved to 15.1±1.7, showing significant differences when compared with preoperative ones ( t=18.064, P=0.000; t=-7.066, P=0.000). The neurological function of ASIA grade were also improved to grade D in 5 cases and grade E in 2 cases, showing significant difference ( Z=-2.530, P=0.011). Conclusion Complex forces and degeneration of lower cervical spine were main reasons of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation. The type of odontoid fracture and neurological deficit status of lower cervical spinal cord were important to guide making strategy of one-stage operation with a satisfactory clinic outcome.
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Affiliation(s)
- Wei Zhang
- Department of Spinal Surgery, Fuyang City People's Hospital, Fuyang Anhui, 236000, P.R.China
| | - Haiyang Yu
- Department of Spinal Surgery, Fuyang City People's Hospital, Fuyang Anhui, 236000,
| | - Chengmin Liang
- Department of Spinal Surgery, Fuyang City People's Hospital, Fuyang Anhui, 236000, P.R.China
| | - Wei Jiao
- Department of Spinal Surgery, Fuyang City People's Hospital, Fuyang Anhui, 236000, P.R.China
| | - Jie Cao
- Department of Spinal Surgery, Fuyang City People's Hospital, Fuyang Anhui, 236000, P.R.China
| | - Chao Li
- Department of Spinal Surgery, Fuyang City People's Hospital, Fuyang Anhui, 236000, P.R.China
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Carter AW, Jacups SP, Ackland HM, Wright A, Lawson A, Armit D, Mooney R. Spinal clearance practices at a regional Australian hospital: A window to major trauma management performance outside metropolitan trauma centres. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2017. [DOI: 10.5339/jemtac.2017.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Prevention of secondary spinal injury via spinal protection measures is a standard component of trauma management, and a high-quality spinal clearance process is imperative in achieving this aim. To evaluate the current practice with a view to achieving best practice, we sought to examine the spinal clearance process and outcomes at a regional Australian referral hospital, which services a large geographical catchment area. Methods: A retrospective review of medical records of all patients with major trauma who presented to an Australian regional hospital during 2014 was conducted. The primary outcome measure was missed or delayed diagnosis of spinal injury. Secondary outcome measures included compliance with internationally accepted spinal clearance process measures, timing and choice of appropriate imaging modalities, rates of spinal injury and documentation of spinal clearance. Results: Of the 112 patients with major trauma who met the study eligibility criteria and were discharged from hospital during the study period from 1 January to 31 December 2014, 11 spinal injuries were missed or delayed in diagnosis. The injuries occurred in 3.6% of patients and all were thoracolumbar spine (TLS) injuries. The predominant reasons for missed or delayed diagnosis were reduced sensitivity of plain X-ray compared with computed tomography for spinal injury screening and incomplete full spinal imaging to detect non-contiguous fractures. Conclusion: Evidence-based clinical decision rules are imperative in ascertaining the need for imaging in the TLS and would be enhanced by an internationally recognised definition of clinical significance based on injury morphology rather than clinician management decision alone. In addition, regional hospitals may have limited capacity to achieve spinal clearance, and other trauma quality assurance standards commensurate with national and international benchmarks without the valuable performance feedback provided by state trauma registries, as is currently the case in Queensland.
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Affiliation(s)
- Angus W. Carter
- 1Intensive Care Department, Cairns Hospital, Queensland, Australia
| | - Susan P. Jacups
- 1Intensive Care Department, Cairns Hospital, Queensland, Australia
- 2The Cairns Institute, James Cook University, Cairns, Queensland, Australia
| | - Helen M. Ackland
- 3Intensive Care Department, The Alfred Hospital, Melbourne, Australia
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 5Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Wright
- 6Department of Anaesthesia and Perioperative Medicine, Cairns Hospital, Queensland, Australia
| | - Amy Lawson
- 7Department of Surgery, Cairns Hospital, Queensland, Australia
| | - Drew Armit
- 8Department of Orthopaedic Surgery, Cairns Hospital, Queensland, Australia
| | - Richard Mooney
- 9Department of Emergency Medicine, Cairns Hospital, Queensland, Australia
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Anandasivam NS, Russo GS, Fischer JM, Samuel AM, Ondeck NT, Swallow MS, Chung SH, Bohl DD, Grauer JN. Analysis of Bony and Internal Organ Injuries Associated With 26,357 Adult Femoral Shaft Fractures and Their Impact on Mortality. Orthopedics 2017; 40:e506-e512. [PMID: 28358976 DOI: 10.3928/01477447-20170327-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 02/15/2017] [Indexed: 02/03/2023]
Abstract
The spectrum of injuries associated with femoral shaft fractures and those injuries' association with mortality have not been well delineated previously. Patients in the National Trauma Data Bank who presented with femoral shaft fractures from 2011 to 2012 were analyzed in 3 age groups (18-39, 40-64, and 65+ years). For each group, modified Charlson Comorbidity Index (CCI), mechanism of injury (MOI), injury severity score (ISS), and associated injuries were reported. Multivariate logistic regression was used to identify predictors of mortality. Among the 26,357 patients with femoral shaft fractures, modified CCIs gradually increased with increasing age category and ISS decreased. Motor vehicle accidents were the most common MOI in the younger 2 age groups, whereas falls were the most common MOI in the 65 years and older age group. The top 3 associated bony injuries for the study cohort as a whole were tibia/fibula (20.5%), ribs/sternum (19.1%), and non-shaft femur (18.9%, of which 5.8% of the total cohort were femoral neck) fractures. The top 3 associated internal organ injuries were lung (18.9%), intracranial (13.5%), and liver (6.2%), injuries. A multivariate mortality analysis showed that increasing age, increasing comorbidity burden, and associated injuries all had independent associations with mortality. The injuries most associated with mortality were thoracic organ injuries (adjusted odds ratio [AOR]=3.53), head injuries (AOR=2.93), abdominal organ injuries (AOR=2.78), and pelvic fractures (AOR=1.80). This study used a large, nationwide sample of trauma patients to profile injuries associated with femoral shaft fractures. Associations between injuries and mortality underscore the importance of these findings. [Orthopedics. 2017; 40(3):e506-e512.].
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Galeiras Vázquez R, Ferreiro Velasco ME, Mourelo Fariña M, Montoto Marqués A, Salvador de la Barrera S. Update on traumatic acute spinal cord injury. Part 1. Med Intensiva 2017; 41:237-247. [PMID: 28161028 DOI: 10.1016/j.medin.2016.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/30/2016] [Accepted: 11/02/2016] [Indexed: 12/11/2022]
Abstract
Traumatic spinal cord injury requires a multidisciplinary approach both for specialized treatment of the acute phase and for dealing with the secondary complications. A suspicion or diagnosis of spinal cord injury is the first step for a correct management. A review is made of the prehospital management and characteristics of the acute phase of spinal cord injury. Respiratory monitoring for early selective intubation, proper identification and treatment of neurogenic shock are essential for the prevention of secondary spinal cord injury. The use of corticosteroids is currently not a standard practice in neuroprotective treatment, and hemodynamic monitoring and early surgical decompression constitute the cornerstones of adequate management. Traumatic spinal cord injury usually occurs as part of multiple trauma, and this can make diagnosis difficult. Neurological examination and correct selection of radiological exams prevent delayed diagnosis of spinal cord injuries, and help to establish the prognosis.
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Affiliation(s)
- R Galeiras Vázquez
- Unidad de Cuidados Intensivos, Complexo Hospitalario Universitario de A Coruña, A Coruña, España.
| | - M E Ferreiro Velasco
- Unidad de Lesionados Medulares, Complexo Hospitalario Universitario de A Coruña, A Coruña, España
| | - M Mourelo Fariña
- Unidad de Cuidados Intensivos, Complexo Hospitalario Universitario de A Coruña, A Coruña, España
| | - A Montoto Marqués
- Unidad de Lesionados Medulares, Complexo Hospitalario Universitario de A Coruña, A Coruña, España; Departamento de Medicina, Universidad de A Coruña, A Coruña, España
| | - S Salvador de la Barrera
- Unidad de Lesionados Medulares, Complexo Hospitalario Universitario de A Coruña, A Coruña, España
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Abstract
Sub-axial cervical spine injuries are commonly seen in patients with blunt trauma. They may be associated with spinal cord injury resulting in tetraplegia and severe permanent disability. Immobilization of the neck, maintenance of blood pressure and oxygenation, rapid clinical and radiological assessment of all injuries, and realignment of the spinal column are the key steps in the emergency management of these injuries. The role of intravenous methylprednisolone administration in acute spinal cord injuries remains controversial. The definitive management of these injuries is based upon recognition of the fracture pattern, assessment of the degree of instability, the presence or absence of neurologic deficit, and other patient related factors that may influence the outcome. Nonoperative treatment comprises of some form of external immobilization for 8 to 12 weeks, followed by imaging to assess fracture healing, and to rule out instability. The goals of surgery are realignment of the vertebral column, decompression of the neural elements and instrumented stabilization.
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Affiliation(s)
- Gautam Zaveri
- Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India,Address for correspondence: Dr. Gautam Zaveri, 302 Bhaveshwar Kutir, 4th Road Rajawadi, Ghatkopar (East), Mumbai - 400 077, Maharashtra, India. E-mail:
| | - Gurdip Das
- Sunshine Hospitals and Trauma Centre, Bhubhaneshwar, Odisha, India
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Zhang Y, Zhou Z, Wu C, Zhao D, Wang C, Cheng X, Cai W, Wang L, Duanmu Y, Zhang C, Tian W. Population-Stratified Analysis of Bone Mineral Density Distribution in Cervical and Lumbar Vertebrae of Chinese from Quantitative Computed Tomography. Korean J Radiol 2016; 17:581-9. [PMID: 27587947 PMCID: PMC5007385 DOI: 10.3348/kjr.2016.17.5.581] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 05/23/2016] [Indexed: 01/22/2023] Open
Abstract
Objective To investigate the bone mineral density (BMD) of cervical vertebrae in a population-stratified manner and correlate with that of the lumbar vertebrae. Materials and Methods Five hundred and ninety-eight healthy volunteers (254 males, 344 females), ranging from 20 to 64 years of age, were recruited for volumetric BMD (vBMD) measurements by quantitative computed tomography. Basic information (age, height, weight, waistline, and hipline), and vBMD of the cervical and lumbar vertebrae (C2–7 and L2–4) were recorded. Comparisons among sex, age groups and different levels of vertebrae were analyzed using analysis of variance. Linear regression was performed for relevance of different vertebral levels. Results The vBMD of cervical and lumbar vertebrae was higher in females than males in each age group. The vBMD of the cervical and lumbar vertebrae in males and the vBMD of lumbar vertebrae in females decreased with aging. In each age group, the vBMD of the cervical vertebrae was higher than that of the lumbar vertebrae with gradual decreases from C2 to C7 except for C3; moreover, the vBMD of C6 and C7 was significantly different from that of C2–5. Correlations of vBMD among different cervical vertebrae (females: r = 0.62–0.94; males: r = 0.63–0.94) and lumbar vertebrae (males: r = 0.93–0.98; females: r = 0.82–0.97) were statistically significant at each age group. Conclusion The present study provided normative data of cervical vertebrae in an age- and sex-stratified manner. Sex differences in vBMD prominently vary with age, which can be helpful to design a more comprehensive pre-operative surgical plan.
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Affiliation(s)
- Yong Zhang
- Department of Radiology, The Fourth Clinical Medical College of Peking University, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Zhuang Zhou
- Department of Orthopedic Oncology, The Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
| | - Cheng'ai Wu
- Beijing Institute of Traumatology and Orthopedics, Beijing 100035, China
| | - Danhui Zhao
- Beijing Institute of Traumatology and Orthopedics, Beijing 100035, China
| | - Chao Wang
- Beijing Institute of Traumatology and Orthopedics, Beijing 100035, China
| | - Xiaoguang Cheng
- Department of Radiology, The Fourth Clinical Medical College of Peking University, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Wei Cai
- Department of Radiology, The Fourth Clinical Medical College of Peking University, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Ling Wang
- Department of Radiology, The Fourth Clinical Medical College of Peking University, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Yangyang Duanmu
- Department of Radiology, The Fourth Clinical Medical College of Peking University, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Chenxin Zhang
- Department of Radiology, The Fourth Clinical Medical College of Peking University, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Wei Tian
- Department of Spine Surgery, The Fourth Clinical Medical College of Peking University, Beijing Jishuitan Hospital, Beijing 100035, China
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Perez-Orribo L, Kalb S, Snyder LA, Hsu F, Malhotra D, Lefevre RD, Elhadi AM, Newcomb AGUS, Theodore N, Crawford NR. Comparison of CT versus MRI measurements of transverse atlantal ligament integrity in craniovertebral junction injuries. Part 2: A new CT-based alternative for assessing transverse ligament integrity. J Neurosurg Spine 2016; 24:903-9. [DOI: 10.3171/2015.9.spine13807] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The rule of Spence is inaccurate for assessing integrity of the transverse atlantal ligament (TAL). Because CT is quick and easy to perform at most trauma centers, the authors propose a novel sequence of obtaining 2 CT scans to improve the diagnosis of TAL impairment. The sensitivity of a new CT-based method for diagnosing a TAL injury in a cadaveric model was assessed.
METHODS
Ten human cadaveric occipitocervical specimens were mounted horizontally in a supine posture with wooden inserts attached to the back of the skull to maintain a neutral or flexed (10°) posture. Specimens were scanned in neutral and flexed postures in a total of 4 conditions (3 conditions in each specimen): 1) intact (n = 10); either 2A) after a simulated Jefferson fracture with an intact TAL (n = 5) or 2B) after a TAL disruption with no Jefferson fracture (n = 5); and 3) after TAL disruption and a simulated Jefferson fracture (n = 10). The atlantodental interval (ADI) and cross-sectional canal area were measured.
RESULTS
From the neutral to the flexed posture, ADI increased an average of 2.5% in intact spines, 6.25% after a Jefferson fracture without TAL disruption, 34% after a TAL disruption without fracture, and 25% after TAL disruption with fracture. The increase in ADI was significant with both TAL disruption and TAL disruption and fracture (p < 0.005) but not in the other 2 conditions (p > 0.6). Changes in spinal canal area were not significant (p > 0.70).
CONCLUSIONS
This novel method was more sensitive than the rule of Spence for evaluating the integrity of the TAL on CT and does not increase the risk of further neurological damage.
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Affiliation(s)
| | - Samuel Kalb
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Laura A. Snyder
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Forrest Hsu
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | | | - Ali M. Elhadi
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Nicholas Theodore
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Kanna RM, Gaike CV, Mahesh A, Shetty AP, Rajasekaran S. Multilevel non-contiguous spinal injuries: incidence and patterns based on whole spine MRI. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1163-9. [PMID: 26329650 DOI: 10.1007/s00586-015-4209-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 08/22/2015] [Accepted: 08/22/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Multi-level non-contiguous spinal injuries are not uncommon and their incidence varies from 1.6 to 77% depending on the type of imaging modality used. Delayed diagnosis and missed spinal injuries in non-contiguous spine fractures have been frequently described which can result in significant pain, deformity and neurological deficit. The efficacy of whole spine MRI in detecting asymptomatic significant vertebral fractures is not known. METHODOLOGY Consecutive spinal injury patients treated between 2011 and 2013 were retrospectively evaluated based on clinical and radiographic records. Patients' demographics, mode of injury, presence of associated injuries, clinical symptoms and the presence of neurological deficit were studied. Radiographs of the fractured region and whole spine MRI were evaluated for the presence of multi-level injuries. RESULTS Among 484 patients, 95 (19.62%) patients had multilevel injuries including 86 (17.76%) with non-contiguous injuries. Five common patterns of non-contiguous spinal injuries were observed. Pattern I: cervical and thoracic--29.1%, Pattern II: thoracolumbar and lumbosacral--22.1%, Pattern III: thoracic and thoracolumbar--12.8 %, Pattern IV: cervical and thoracolumbar--9.1% and Pattern V: lumbosacral and associated injuries--9.0 %. The incidence of intra-regional non-contiguous injuries was 17.4%. Whole spine MRI scan detected 24 (28.6%) missed secondary injuries of which 5 were unstable. CONCLUSION The incidence of multilevel non-contiguous spine injury using whole spine MRI imaging is 17.76%. Five different patterns of multi-level non-contiguous injuries were found with the most common pattern being the cervical and thoracic level injuries. The incidence of unstable injuries can be as high as 21% of missed secondary injuries.
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Affiliation(s)
- Rishi Mugesh Kanna
- Department of Orthopaedics, Traumatology and Spine Surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, 641043, India
| | - Chandrasekar V Gaike
- Department of Orthopaedics, Traumatology and Spine Surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, 641043, India
| | - Anupama Mahesh
- Department of Radiology, Ganga Hospital, 313, Mettupalayam road, Coimbatore, 641043, India
| | - Ajoy Prasad Shetty
- Department of Orthopaedics, Traumatology and Spine Surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, 641043, India
| | - S Rajasekaran
- Department of Orthopaedics, Traumatology and Spine Surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, 641043, India.
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Sebastian AS, Fogelson JL, Dekutoski MB, Nassr AN. Multiple noncontiguous spinal fractures and occipitocervical dislocation in a patient with ankylosing spondylitis treated with a hybrid open and percutaneous spinal fixation technique: a case report. Spine J 2015; 15:e1-5. [PMID: 25666695 DOI: 10.1016/j.spinee.2015.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 01/06/2015] [Accepted: 02/03/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal fractures occur with a greater frequency in ankylosing spondylitis (AS) patients. Treatment of these fractures is complicated because of a higher incidence of medical comorbidities, higher rate of neurologic deficits, and higher risk of neurologic deterioration. PURPOSE To report a case report of a novel, combined open and percutaneous surgical techniques used for the treatment of multiple noncontiguous spinal fractures in a patient with AS. STUDY DESIGN/SETTING We describe the surgical treatment and the outcome of a patient with AS that sustained an occipitocervical dislocation and two noncontiguous three-column extension injuries using a hybrid technique with open occipital to T3 fusion and percutaneous T5-L1 instrumentation at a tertiary care facility. PATIENT SAMPLE A 77-year-old man with multiple comorbidities and newly diagnosed AS. OUTCOME MEASURES Two-year clinical and radiographic outcome of a patient treated surgically for multiple spine injuries in the setting of an ankylosed spine. METHODS The patient was treated with a hybrid approach using both open fusion and percutaneous instrumentation techniques. RESULTS At 2 years postoperatively, the patient had recovered ambulatory ability and had a good clinical outcome. CONCLUSIONS We describe a unique case of noncontiguous spinal trauma in a medically complex patient with AS treated with a hybrid open and percutaneous technique to minimize surgical insult and blood loss, with a good clinical and radiographic outcome 2 years postoperatively.
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Affiliation(s)
- Arjun S Sebastian
- The Department of Orthopedic Surgery, Mayo Clinic, 200 First St, S.W., Rochester, MN 55905, USA
| | - Jeremy L Fogelson
- The Department of Orthopedic Surgery, Mayo Clinic, 200 First St, S.W., Rochester, MN 55905, USA
| | - Mark B Dekutoski
- The Department of Orthopedic Surgery, Mayo Clinic, 200 First St, S.W., Rochester, MN 55905, USA
| | - Ahmad N Nassr
- The Department of Orthopedic Surgery, Mayo Clinic, 200 First St, S.W., Rochester, MN 55905, USA.
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Taneja A, Berry CA, Rao RD. Initial Management of the Patient With Cervical Spine Injury. ACTA ACUST UNITED AC 2013. [DOI: 10.1053/j.semss.2012.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
CONTEXT Head-first sports-induced impacts cause cervical fractures and dislocations and spinal cord lesions. In previous biomechanical studies, researchers have vertically dropped human cadavers, head-neck specimens, or surrogate models in inverted postures. OBJECTIVE To develop a cadaveric neck model to simulate horizontally aligned, head-first impacts with a straightened neck and to use the model to investigate biomechanical responses and failure mechanisms. DESIGN Descriptive laboratory study. SETTING Biomechanics research laboratory. PATIENTS OR OTHER PARTICIPANTS Five human cadaveric cervical spine specimens. INTERVENTION(S) The model consisted of the neck specimen mounted horizontally to a torso-equivalent mass on a sled and carrying a surrogate head. Head-first impacts were simulated at 4.1 m/s into a padded, deformable barrier. MAIN OUTCOME MEASURE(S) Time-history responses were determined for head and neck loads, accelerations, and motions. Average occurrence times of the compression force peaks at the impact barrier, occipital condyles, and neck were compared. RESULTS The first local compression force peaks at the impact barrier (3070.0 ± 168.0 N at 18.8 milliseconds), occipital condyles (2868.1 ± 732.4 N at 19.6 milliseconds), and neck (2884.6 ± 910.7 N at 25.0 milliseconds) occurred earlier than all global compression peaks, which reached 7531.6 N in the neck at 46.6 milliseconds (P < .001). Average peak head motions relative to the torso were 6.0 cm in compression, 2.4 cm in posterior shear, and 6.4° in flexion. Neck compression fractures included occipital condyle, atlas, odontoid, and subaxial comminuted burst and facet fractures. CONCLUSIONS Neck injuries due to excessive axial compression occurred within 20 milliseconds of impact and were caused by abrupt deceleration of the head and continued forward torso momentum before simultaneous rebound of the head and torso. Improved understanding of neck injury mechanisms during sports-induced impacts will increase clinical awareness and immediate care and ultimately lead to improved protective equipment, reducing the frequency and severity of neck injuries and their associated societal costs.
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Affiliation(s)
- Paul C Ivancic
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 333 Cedar Street, PO Box 208071, New Haven, CT 06520-8071, USA.
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25
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Bensch FV, Koivikko MP, Koskinen SK. Multidetector computed tomography of spinal fractures. Semin Roentgenol 2012; 47:330-41. [PMID: 22929692 DOI: 10.1053/j.ro.2012.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Frank V Bensch
- Department of Diagnostic Radiology, Töölö Trauma Center, Helsinki University Central Hospital (HUCH), Helsinki, Finland.
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26
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Abstract
Failure to recognize spinal column or spinal cord injuries, or improper treatment of them, can have catastrophic and often irreversible neurologic consequences. Although the initial assessment is often shared with emergency care personnel, an orthopaedic surgeon's perspective can elevate the priority of spinal care to the level that is warranted. An accurate early appraisal, including complete neurologic assessment, is critical. All aspects of emergent care, including optimal immobilization precautions, resuscitation, and choice of imaging modalities, should be systematically reviewed, and practice guidelines should be adopted by each institution. Increased vigilance is required in patients with underlying ankylosing spinal conditions. The use of CT in the symptomatic patient is established, but the use of cervical MRI in the obtunded individual is contentious. By informing decisions around appropriate preliminary treatment, particularly for persons with neurologic deficits or those at high risk for developing neurologic impairment, long-term outcomes can be optimized.
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