Is a pelvic fracture a predictor for thoracolumbar spine fractures after blunt trauma?

Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

Polytraumatized patients with spinal injuries require tailor-made treatment plans. Severity of both spinal and concomitant injuries determine timing of spinal surgery. Aim of this study was to evaluate the role of spinal injury localization, severity and concurrent injury patterns on timing of surgery and subsequent outcome.

METHODS

The TraumaRegister DGU® was utilized and patients, aged ≥16 years, with an Injury Severity Score (ISS) ≥16 and diagnosed with relevant spinal injuries (abbreviated injury scale, AIS ≥ 3) were selected. Concurrent spinal and non-spinal injuries were analysed and the relation between injury severity, concurrent injury patterns and timing of spinal surgery was determined.

RESULTS

12.596 patients with a mean age of 50.8 years were included. 7.2% of patients had relevant multisegmental spinal injuries. Furthermore, 50% of patients with spine injuries AIS ≥3 had a more severe non-spinal injury to another body part. ICU and hospital stay were superior in patients treated within 48 hrs for lumbar and thoracic spinal injuries. In cervical injuries early intervention (<48 hrs) was associated with increased mortality rates (9.7 vs 6.3%).

CONCLUSIONS

The current multicentre study demonstrates that polytrauma patients frequently sustain multiple spinal injuries, and those with an index spine injury may therefore benefit from standardized whole-spine imaging. Moreover, timing of surgical spinal surgery and outcome appear to depend on the severity of concomitant injuries and spinal injury localization. Future prospective studies are needed to identify trauma characteristics that are associated with improved outcome upon early or late spinal surgery.

Patients with combined pelvic and spinal injuries have worse clinical and operative outcomes than patients with isolated pelvic injuries analysis of the German Pelvic Registry

Background

Pelvic fractures are often associated with spine injury in polytrauma patients. This study aimed to determine whether concomitant spine injury influence the surgical outcome of pelvic fracture.

Methods

We performed a retrospective analysis of data of patients registered in the German Pelvic Registry between January 2003 and December 2017. Clinical characteristics, surgical parameters, and outcomes were compared between patients with isolated pelvic fracture (group A) and patients with pelvic fracture plus spine injury (group B). We also compared apart patients with isolated acetabular fracture (group C) versus patients with acetabular fracture plus spine injury (group D).

Results

Surgery for pelvic fracture was significantly more common in group B than in group A (38.3% vs. 36.6%; p = 0.0002), as also emergency pelvic stabilizations (9.5% vs. 6.7%; p < 0.0001). The mean time to emergency stabilization was longer in group B (137 ± 106 min vs. 113 ± 97 min; p < 0.0001), as well as the mean time until definitive stabilization of the pelvic fracture (7.3 ± 4 days vs. 5.4 ± 8.0 days; p = 0.147). The mean duration of treatment and the morbidity and mortality rates were all significantly higher in group B (p < 0.0001). Operation time was significantly shorter in group C than in group D (176 ± 81 min vs. 203 ± 119 min, p < 0.0001). Intraoperative blood loss was not significantly different between the two groups with acetabular injuries. Although preoperative acetabular fracture dislocation was slightly less common in group D, postoperative fracture dislocation was slightly more common. The distribution of Matta grades was significantly different between the two groups. Patients with isolated acetabular injuries were significantly less likely to have neurological deficit at discharge (94.5%; p < 0.0001). In-hospital complications were more common in patients with combined spine plus pelvic injuries (groups B and D) than in patients with isolated pelvic and acetabular injury (groups A and C).

Conclusions

Delaying definitive surgical treatment of pelvic fractures due to spinal cord injury appears to have a negative impact on the outcome of pelvic fractures, especially on the quality of reduction of acetabular fractures.

Timing of intervention for spinal injury in patients with polytrauma

OBJECTIVE

The optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores.

METHODS

A narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995-2020) based on the keywords - polytrauma OR multiple trauma AND spine fracture AND timing, present in "All the fields" of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed.

RESULTS

Spine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, "damage control" internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay.

CONCLUSION

Recognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.

Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging

BACKGROUND

Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging.

OBJECTIVE

Our aim was to quantify the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients.

METHODS

A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2 × 2 tables, were duplicates, were not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios.

RESULTS

In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1-152.2; I² = 94%; p < 0.001) and negative likelihood ratio (-LR) = 0.43 (95% CI 0.32-0.59; I² = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1-467.9; I² = 87%; p < 0.001) and -LR = 0.04 (95% CI 0.02-0.08; I² = 23%; p = 0.26).

CONCLUSIONS

CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.

Reformatted images of the thoracic and lumbar spine following CT of chest, abdomen, and pelvis in the setting of blunt trauma: are they necessary?

Injuries involving the thoracic and lumbar (TL) spine in the setting of blunt trauma are not uncommon. At our institution, CT of the chest, abdomen, and pelvis (CT CAP) with dedicated reformatted images of the thoracolumbar spine (CT TL) is part of the standard work-up of patients following significant blunt trauma. The purpose of this study was to compare the detection rate of TL spine fractures on routine trauma CT CAP with reformatted CT TL spine images and determine whether these reformatted images detect additional fractures and if these altered patient management. The imaging records of 1000 consecutive patients who received blunt trauma protocol CT CAP with CT TL spine reformats were reviewed to determine identification of TL spine fracture in each report. Fracture type and location were documented. Of the 896 patients, 66 (7.4 %) had fractures of the TL spine identified on either CT CAP or CT TL spine. Of these 66 patients, 40 (60.6 %) had fractures identified on both CT CAP and CT TL spine and 24 (36.4 %) had fractures identified on CT TL spine images alone. Fourteen patients required treatment with surgery or bracing, 4 (28.6 %) of which had fractures identified on reformatted TL spine imaging only. In conclusion, a significant number of fractures are detected on TL spine reformats that are not identified on CT CAP alone, altering patient management in a few cases and suggesting that dedicated TL spine reformats should be a standard part of the work-up of blunt trauma patients.

Occupant and crash characteristics in thoracic and lumbar spine injuries resulting from motor vehicle collisions

BACKGROUND CONTEXT

Motor vehicle collisions (MVC) are a leading cause of thoracic and lumbar (T and L) spine injuries. Mechanisms of injury in vehicular crashes that result in thoracic and lumbar fractures and the spectrum of injury in these occupants have not been extensively studied in the literature.

PURPOSE

The objective was to investigate the patterns of T and L spine injuries after MVC; correlate these patterns with restraint use, crash characteristics, and demographic variables; and study the associations of these injuries with general injury morbidity and fatality.

STUDY DESIGN/SETTING

The study design is a retrospective study of a prospectively gathered database.

PATIENT SAMPLE

Six hundred thirty-one occupants with T and L (T1-L5) spine injuries from 4,572 occupants included in the Crash Injury Research and Engineering Network (CIREN) database between 1996 and 2011 were included in this study.

OUTCOME MEASURES

No clinical outcome measures were evaluated in this study.

METHODS

The CIREN database includes moderate to severely injured occupants from MVC involving vehicles manufactured recently. Demographic, injury, and crash data from each patient were analyzed for correlations between patterns of T and L spine injuries, associated extraspinal injuries and overall injury severity score (ISS), type and use of seat belts, and other crash characteristics. T and L spine injuries patterns were categorized using a modified Denis' classification to include extension injuries as a separate entity.

RESULTS

T and L spine injuries were identified in 631 of 4,572 vehicle occupants, of whom 299 sustained major injuries (including 21 extension injuries) and 332 sustained minor injuries. Flexion-distraction injuries were more prevalent in children and young adults and extension injuries in older adults (mean age, 65.7 years). Occupants with extension injuries had a mean body mass index of 36.0 and a fatality rate of 23.8%, much higher than the fatality rate for the entire cohort (10.9%). The most frequent extraspinal injuries (Abbreviated Injury Scale Grade 2 or more) associated with T and L spine injuries involved the chest (seen in 65.6% of 631 occupants). In contrast to occupants with major T and L spine injuries, those with minor T and L spine injuries showed a strikingly greater association with pelvic and abdominal injuries. Occupants with minor T and L spine injuries had a higher mean ISS (27.1) than those with major T and L spine injuries (25.6). Among occupants wearing a three-point seat belt, 35.3% sustained T and L spine injuries, whereas only 11.6% of the unbelted occupants sustained T and L spine injuries. Three-point belted individuals were more likely to sustain burst fractures, whereas two-point belted occupants sustained flexion-distraction injuries most often and unbelted occupants had a predilection for fracture-dislocations of the T and L spines. Three-point seat belts were protective against neurologic injury, higher ISS, and fatality.

CONCLUSIONS

T and L spine fracture patterns are influenced by the age of occupant and type and use of seat belts. Despite a reduction in overall injury severity and mortality, seat belt use is associated with an increased incidence of T and L spine fractures. Minor T and L spine fractures were associated with an increased likelihood of pelvic and abdominal injuries and higher ISSs, demonstrating their importance in predicting overall injury severity. Extension injuries occurred in older obese individuals and were associated with a high fatality rate. Future advancements in automobile safety engineering should address the need to reduce T and L spine injuries in belted occupants.