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Sunder A, Chhabra H, Aryal A. Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review. J Clin Orthop Trauma 2023; 43:102190. [PMID: 37538298 PMCID: PMC10393813 DOI: 10.1016/j.jcot.2023.102190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/16/2023] [Indexed: 08/05/2023] Open
Abstract
The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.
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Affiliation(s)
- Aditya Sunder
- Indian Spinal Injuries Centre, New Delhi, 110070, India
| | - H.S. Chhabra
- Indian Spinal Injuries Centre, New Delhi, 110070, India
| | - Aayush Aryal
- Indian Spinal Injuries Centre, New Delhi, 110070, India
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Lau L, Ajzenberg H, Haas B, Wong CL. Trauma in the Aging Population. Emerg Med Clin North Am 2023; 41:183-203. [DOI: 10.1016/j.emc.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Engelbart J, Zhou P, Johnson J, Lilienthal M, Zhou Y, Ten-Eyck P, Galet C, Skeete D. Geriatric clinical screening tool for cervical spine injury after ground-level falls. Emerg Med J 2021; 39:301-307. [PMID: 34108196 DOI: 10.1136/emermed-2020-210693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 05/28/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND A consistent approach to cervical spine injury (CSI) clearance for patients 65 and older remains a challenge. Clinical clearance algorithms like the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have variable accuracy and the Canadian C-spine rule excludes older patients. Routine CT of the cervical spine is performed to rule out CSI but at an increased cost and low yield. Herein, we aimed to identify predictive clinical variables to selectively screen older patients for CSI. METHODS The University of Iowa's trauma registry was interrogated to retrospectively identify all patients 65 years and older who presented with trauma from a ground-level fall from January 2012 to July 2017. The relationship between predictive variables (demographics, NEXUS criteria and distracting injuries) and presence of CSI was examined using the generalised linear modelling (GLM) framework. A training set was used to build the statistical models to identify clinical variables that can be used to predict CSI and a validation set was used to assess the reliability and consistency of the model coefficients estimated from the training set. RESULTS Overall, 2312 patients ≥65 admitted for ground-level falls were identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best predictive model for CSI included midline tenderness, focal neurological deficit and signs of trauma to the head/face, with midline tenderness highly predictive of CSI (OR=22.961 (15.178-34.737); p<0.001). The negative predictive value (NPV) for this model was 95.1% (93.9%-96.3%). In the absence of midline tenderness, the best model included focal neurological deficit (OR=2.601 (1.340-5.049); p=0.005) and signs of trauma to the head/face (OR=3.024 (1.898-4.815); p<0.001). The NPV was 94.3% (93.1%-95.5%). CONCLUSION Midline tenderness, focal neurological deficit and signs of trauma to the head/face were significant in this older population. The absence of all three variables indicates lower likelihood of CSI for patients≥65. Future observational studies are warranted to prospectively validate this model.
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Affiliation(s)
- Jacklyn Engelbart
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Peige Zhou
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Jenna Johnson
- Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Michele Lilienthal
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Yunshu Zhou
- Institute for Clinical and Translational Science, Biostatistics, Epidemiology, and Research Design Core, The University of Iowa, Iowa City, Iowa, USA
| | - Patrick Ten-Eyck
- Institute for Clinical and Translational Science, Biostatistics, Epidemiology, and Research Design Core, The University of Iowa, Iowa City, Iowa, USA
| | - Colette Galet
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Dionne Skeete
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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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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Saragiotto BT, Maher CG, Lin CWC, Verhagen AP, Goergen S, Michaleff ZA. Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) for detecting clinically important cervical spine injury following blunt trauma. Hippokratia 2018. [DOI: 10.1002/14651858.cd012989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Bruno T Saragiotto
- Sydney Medical School, The University of Sydney; Musculoskeletal Health Sydney, School of Public Health; Sydney Australia
| | - Christopher G Maher
- The University of Sydney; Sydney School of Public Health; Level 10 North, King George V Building, Missenden Road, Camperdown Sydney NSW Australia 2050
| | - Chung-Wei Christine Lin
- Sydney School of Public Health, The University of Sydney; Musculoskeletal Health Sydney; Level 10, North, King George V Building, Royal Prince Alfred Hospital (C39) Sydney New South Wales Australia 2050
| | - Arianne P Verhagen
- University of Technology Sydney; Department of Physiotherapy; Sydney Australia
| | - Stacy Goergen
- Southern Health; Diagnostic Imaging, Monash Medical Centre; 246 Clayton Road Clayton Melbourne VIC Australia 3144
| | - Zoe A Michaleff
- Keele University; Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences; Keele Staffordshire UK ST5 5BG
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Beckmann NM, Cai C, Spence SC, Prasarn ML, Clark West O. Is elevated body mass index protective against cervical spine injury in adults? Emerg Radiol 2018; 25:415-424. [PMID: 29603036 DOI: 10.1007/s10140-018-1602-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 03/23/2018] [Indexed: 01/01/2023]
Abstract
PURPOSE Correlate body mass index (BMI) with incidence and type of cervical spine injury seen on CT in adult patients presenting with blunt trauma. MATERIALS AND METHODS Retrospective chart review of all adult blunt trauma patients who had a cervical spine CT performed at our level 1 trauma center during an approximately 3-year period. RESULTS A statistically significant (p = 0.01) difference in cervical spine injury incidence was present between different BMI groups. Cervical spine injury incidence was 7.7% for underweight (BMI ≤ 18) patients, 7.1% for normal weight (BMI 18-25) patients, 6.2% for overweight/obese (BMI 25-35) patients, and 4.7% for morbidly obese (BMI > 35) patients. Using BMI > 18-25 as a reference group, females with BMI > 25-35 had an adjusted odds ratio (aOR) of 0.56 (CI 0.41-0.75) and females with BMI > 35 had an aOR of 0.42 (CI 0.26-0.70). Males with a BMI ≤ 18 had an aOR of 2.20 (CI 1.12-4.32) and males with BMI > 35 had an aOR of 0.66 (CI 0.46-0.95). A particularly low incidence of cervical spine injury was observed in patients older than 65 in the obese group with a cervical spine injury rate of only 1.4% in this patient population. No statistical significant difference was seen in injury morphology across the BMI groups. CONCLUSION An inverse relationship exists between BMI and the overall incidence of cervical spine injury. This protective effect appears to be influenced by gender with elevated BMI having lower relative odds of cervical spine injury in women than in men. A particularly low rate of cervical spine injury was identified in obese patients over the age of 65. Routine imaging of all elderly, obese trauma patients with low energy mechanism of injury may not be warranted.
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Affiliation(s)
- Nicholas M Beckmann
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA.
| | - Chunyan Cai
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
- Biostatistics/Epidemiology/Research/Design Core, Center for Clinical and Translational Sciences, The University of Texas Health Science Center at Houston, 6410 Fannin, UTPB 1100.08, Houston, TX, 77030, USA
| | - Susanna C Spence
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA
| | - Mark L Prasarn
- Department of Orthopedic Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX, 77030, USA
| | - O Clark West
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA
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Thesleff T, Niskakangas T, Luoto T, Iverson GL, Öhman J, Ronkainen A. Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from 1987 to 2010. Spine J 2018; 18:430-438. [PMID: 28822822 DOI: 10.1016/j.spinee.2017.08.231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/17/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Fall-induced injuries in patients are increasing in number, and they often lead to serious consequences, such as cervical spine injuries (CSI). CSI diagnostics remain a challenge despite improved radiological services. PURPOSE Our aim is to define the incidence and risk factors for diagnostic errors among patients who died following a CSI. STUDY DESIGN/SETTING A retrospective death certificate-based study of the whole population of Finland was carried out. PATIENT SAMPLE We identified 2,041 patients whose death was, according to the death certificate, either directly or indirectly caused by a CSI. OUTCOME MEASURES Demographics, injury- and death-related data, and adverse event (AE)-related data were the outcome measures. METHODS All death certificates between the years 1987 and 2010 from Statistics Finland that identified a CSI as a cause death were reviewed to identify preventable AEs with the emphasis on diagnostic errors. RESULTS Of the 2,041 patients with CSI-related deaths, 36.5% (n=744) survived at least until the next day. Errors in CSI diagnostics were found in 13.8% (n=103) of those who died later than the day of injury. Those with diagnostic errors were significantly older (median age 79.4 years, 95% confidence interval 75.9-80.1 vs. 74.9, 95% confidence interval 70.2-72.9, p<.001) and the mechanism of injury was significantly more often a fall (86.4%, n=89 vs. 69.7%, n=447, p=.002) compared with those who did not have a diagnostic error. The incidence of diagnostic errors increased slightly during the 24-year study period. CONCLUSIONS Cervical spine injury diagnostics remain difficult despite improved radiological services. The majority of the patients subjected to diagnostic errors are fragile elderly people with reduced physical capacity. In our analysis, preventable AEs and diagnostic errors were most commonly associated with ground-level falls.
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Affiliation(s)
- Tuomo Thesleff
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland.
| | - Tero Niskakangas
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Teemu Luoto
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Center for Health and Rehabilitation Research, 79/96 Thirteenth Street, Charlestown Navy Yard, Charlestown, MA, 02129, Massachusetts, USA
| | - Juha Öhman
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Antti Ronkainen
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
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Jambhekar A, Lindborg R, Chan V, Fulginiti A, Fahoum B, Rucinski J. Over the hill and falling down: Can the NEXUS criteria be applied to the elderly? Int J Surg 2018; 49:56-59. [DOI: 10.1016/j.ijsu.2017.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/19/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
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Paykin G, O'Reilly G, Ackland H, Mitra B. Review article: NEXUS criteria to rule out cervical spine injury among older patients: A systematic review. Emerg Med Australas 2017; 30:450-455. [DOI: 10.1111/1742-6723.12880] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/15/2017] [Accepted: 09/09/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Gabriel Paykin
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Gerard O'Reilly
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Helen Ackland
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Intensive Care Department; The Alfred; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
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Lindborg R, Jambhekar A, Chan V, Laskey D, Rucinski J, Fahoum B. Distracting injury defined: does an isolated hip fracture constitute a distracting injury for clearance of the cervical spine? Emerg Radiol 2017; 25:35-39. [PMID: 28936568 DOI: 10.1007/s10140-017-1555-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/15/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES As the population within the USA ages, the number of hip fractures seen yearly in the emergency department is expected to rise. According to the NEXUS criteria, many of these patients receive computerized tomographic scan (CT) evaluation of the cervical spine because a hip fracture may constitute a distracting injury. The objective of this study is to determine if an isolated hip fracture constitutes a distracting injury which requires imaging of the cervical spine. METHODS Data were prospectively collected on 158 trauma patients with isolated hip fractures between April 1, 2015 and March 9, 2016. Patient demographics were analyzed and compared to the National Emergency X-Radiography Utilization Study (NEXUS). RESULTS Patients with isolated hip fractures were predominantly elderly, on average 78.6 +/- 15.9 years old, and 94.3% of these injuries occurred after a fall from standing. Only one patient also had a cervical spine fracture which was not clinically significant. When compared to the established rate of cervical spine injury of 2.4%, the absolute risk reduction (ARR) was 0.35% (95% CI, - 1.06 to 1.75%) and the number needed to treat (NNT) was 290. CONCLUSION In the case of an elderly patient with an isolated hip fracture and no cervical midline tenderness, cervical spine imaging may be reserved for those who have other NEXUS criteria for further workup.
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Affiliation(s)
- Ryan Lindborg
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA.
| | - Amani Jambhekar
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
| | - Vincent Chan
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
| | - Daniel Laskey
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
| | - James Rucinski
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
| | - Bashar Fahoum
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
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Paykin G, O'Reilly G, Ackland HM, Mitra B. The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients. Injury 2017; 48:1020-1024. [PMID: 28274471 DOI: 10.1016/j.injury.2017.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 02/15/2017] [Accepted: 02/18/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVE The National Emergency X-Radiography Utilization Study (NEXUS) criteria are used to assess the need for imaging to evaluate cervical spine integrity after injury. The aim of this study was to assess the sensitivity of the NEXUS criteria in older blunt trauma patients. METHODS Patients aged 65 years or older presenting between 1st July 2010 and 30th June 2014 and diagnosed with cervical spine fractures were identified from the institutional trauma registry. Clinical examination findings were extracted from electronic medical records. Data on the NEXUS criteria were collected and sensitivity of the rule to exclude a fracture was calculated. RESULTS Over the study period 231,018 patients presented to The Alfred Emergency & Trauma Centre, of whom 14,340 met the institutional trauma registry inclusion criteria and 4035 were aged ≥65years old. Among these, 468 patients were diagnosed with cervical spine fractures, of whom 21 were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% [95% CI: 92.1%-96.7%] on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% [95% CI: 93.2%-97.2%]. CONCLUSION Compared with the general adult blunt trauma population, the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. We therefore suggest that liberal imaging be considered for older patients regardless of history or examination findings and that the addition of an age criterion to the NEXUS criteria be investigated in future studies.
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Affiliation(s)
- Gabriel Paykin
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia; Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Gerard O'Reilly
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia; Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Helen M Ackland
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia; Intensive Care Department, The Alfred Hospital, Melbourne, Australia
| | - Biswadev Mitra
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia; Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.
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Jawa RS, Singer AJ, Rutigliano DN, McCormack JE, Huang EC, Shapiro MJ, Fields SD, Morelli BN, Vosswinkel JA. Spinal Fractures in Older Adult Patients Admitted After Low-Level Falls: 10-Year Incidence and Outcomes. J Am Geriatr Soc 2016; 65:909-915. [DOI: 10.1111/jgs.14669] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Randeep S. Jawa
- Division of Trauma; Department of Surgery; Stony Brook University School of Medicine; Stony Brook New York
| | - Adam J. Singer
- Department of Emergency Medicine; Stony Brook University School of Medicine; Stony Brook New York
| | - Daniel N. Rutigliano
- Division of Trauma; Department of Surgery; Stony Brook University School of Medicine; Stony Brook New York
| | - Jane E. McCormack
- Division of Trauma; Department of Surgery; Stony Brook University School of Medicine; Stony Brook New York
| | - Emily C. Huang
- Division of Trauma; Department of Surgery; Stony Brook University School of Medicine; Stony Brook New York
| | - Marc J. Shapiro
- Division of Trauma; Department of Surgery; Stony Brook University School of Medicine; Stony Brook New York
| | - Suzanne D. Fields
- Division of Geriatrics; General Internal Medicine, and Hospital Medicine; Department of Medicine; Stony Brook University School of Medicine; Stony Brook New York
| | - Brian N. Morelli
- Spine and Scoliosis Center; Department of Orthopedic Surgery; Stony Brook University School of Medicine; Stony Brook New York
| | - James A. Vosswinkel
- Division of Trauma; Department of Surgery; Stony Brook University School of Medicine; Stony Brook New York
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Tran J, Jeanmonod D, Agresti D, Hamden K, Jeanmonod RK. Prospective Validation of Modified NEXUS Cervical Spine Injury Criteria in Low-risk Elderly Fall Patients. West J Emerg Med 2016; 17:252-7. [PMID: 27330655 PMCID: PMC4899054 DOI: 10.5811/westjem.2016.3.29702] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/08/2016] [Accepted: 03/09/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The National Emergency X-radiography Utilization Study (NEXUS) criteria are used extensively in emergency departments to rule out C-spine injuries (CSI) in the general population. Although the NEXUS validation set included 2,943 elderly patients, multiple case reports and the Canadian C-Spine Rules question the validity of applying NEXUS to geriatric populations. The objective of this study was to validate a modified NEXUS criteria in a low-risk elderly fall population with two changes: a modified definition for distracting injury and the definition of normal mentation. METHODS This is a prospective, observational cohort study of geriatric fall patients who presented to a Level I trauma center and were not triaged to the trauma bay. Providers enrolled non-intoxicated patients at baseline mental status with no lateralizing neurologic deficits. They recorded midline neck tenderness, signs of trauma, and presence of other distracting injury. RESULTS We enrolled 800 patients. One patient fall event was excluded due to duplicate enrollment, and four were lost to follow up, leaving 795 for analysis. Average age was 83.6 (range 65-101). The numbers in parenthesis after the negative predictive value represent confidence interval. There were 11 (1.4%) cervical spine injuries. One hundred seventeen patients had midline tenderness and seven of these had CSI; 366 patients had signs of trauma to the face/neck, and 10 of these patients had CSI. Using signs of trauma to the head/neck as the only distracting injury and baseline mental status as normal alertness, the modified NEXUS criteria was 100% sensitive (CI [67.9-100]) with a negative predictive value of 100 (98.7-100). CONCLUSION Our study suggests that a modified NEXUS criteria can be safely applied to low-risk elderly falls.
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Affiliation(s)
- John Tran
- St. Luke's University Hospital, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Donald Jeanmonod
- St. Luke's University Hospital, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Darin Agresti
- St. Luke's University Hospital, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | | | - Rebecca K Jeanmonod
- St. Luke's University Hospital, Department of Emergency Medicine, Bethlehem, Pennsylvania
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Moore CL, Broder J, Gunn ML, Bhargavan-Chatfield M, Cody D, Cullison K, Daniels B, Gans B, Kennedy Hall M, Gaines BA, Goldman S, Heil J, Liu R, Marin JR, Melnick ER, Novelline RA, Pare J, Repplinger MD, Taylor RA, Sodickson AD. Comparative Effectiveness Research: Alternatives to "Traditional" Computed Tomography Use in the Acute Care Setting. Acad Emerg Med 2015; 22:1465-73. [PMID: 26576033 DOI: 10.1111/acem.12831] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/12/2015] [Indexed: 01/07/2023]
Abstract
Computed tomography (CT) scanning is an essential diagnostic tool and has revolutionized care of patients in the acute care setting. However, there is widespread agreement that overutilization of CT, where benefits do not exceed possible costs or harms, is occurring. The goal was to seek consensus in identifying and prioritizing research questions and themes that involve the comparative effectiveness of "traditional" CT use versus alternative diagnostic strategies in the acute care setting. A modified Delphi technique was used that included input from emergency physicians, emergency radiologists, medical physicists, and an industry expert to achieve this.
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Affiliation(s)
- Christopher L. Moore
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Joshua Broder
- Department of Surgery; Section of Emergency Medicine; Duke University; Durham NC
| | - Martin L. Gunn
- Department of Radiology; University of Washington; Seattle WA
| | | | - Dianna Cody
- Department of Imaging Physics; University of Texas Houston; Houston TX
| | - Kevin Cullison
- Department of Emergency Medicine; Washington University; St. Louis MO
| | - Brock Daniels
- Department of Emergency Medicine; University of California Davis; Davis CA
| | - Bradley Gans
- Department of Radiology; Ohio State University; Cleveland WA
| | - M. Kennedy Hall
- Department of Emergency Medicine; University of Washington; Seattle WA
| | - Barbara A. Gaines
- Division of Pediatric General and Thoracic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Sarah Goldman
- Department of Emergency Medicine; Jacobi Medical Center; New York NY
| | - John Heil
- medint Holdings; LLC d.b.a Imalogix; King of Prussia PA
| | - Rachel Liu
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Jennifer R. Marin
- Departments of Pediatrics and Emergency Medicine; University of Pittsburgh School of Medicine; Pittsburgh PA
- Department of Pediatrics; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Edward R. Melnick
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | | | - Joseph Pare
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Michael D. Repplinger
- Departments of Emergency Medicine and Radiology; University of Wisconsin School of Medicine and Public Health; Madison WI
| | - Richard A. Taylor
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
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Evans D, Vera L, Jeanmonod D, Pester J, Jeanmonod R. Application of National Emergency X-Ray Utilizations Study low-risk c-spine criteria in high-risk geriatric falls. Am J Emerg Med 2015; 33:1184-7. [DOI: 10.1016/j.ajem.2015.05.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 05/16/2015] [Accepted: 05/18/2015] [Indexed: 11/26/2022] Open
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Abstract
BACKGROUND The initial diagnostic procedure of severely injured patients in the emergency room (ER) during the primary survey is first and foremost a clinical examination. The clinical S3 guidelines provide recommendations for the treatment of patients with severe and multiple injuries. OBJECTIVES The study was performed to investigate the reliability of clinical key symptoms or red flags registered in the ER that lead to further diagnostic or therapeutic procedures. MATERIAL AND METHODS An evaluation of key symptoms as a synopsis of the current literature considering aspects of probability calculation and medical experience was carried out. RESULTS Key symptoms registered during the clinical examination are not sufficiently safe to be solely relied upon for further diagnostic and therapeutic decisions. This confirms the sense of purpose of the strict approach according to the advanced trauma life support (ATLS) algorithm. Red flags can serve as a warning to focus on relevant injuries early on. A rational imaging diagnostic procedure must follow.
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McCutcheon L, Schmocker N, Blanksby K, Bhandary K, Deacon B, Reed W. Best Practice in Diagnostic Imaging after Blunt Force Trauma Injury to the Cervical Spine: A Systematic Review. J Med Imaging Radiat Sci 2015; 46:231-240. [PMID: 31052098 DOI: 10.1016/j.jmir.2015.01.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 01/21/2015] [Accepted: 01/30/2015] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The aim of this study was to investigate best practice in evidence-based clinical examinations to determine the diagnostic efficacy of plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) of a cervical spine injury after blunt force trauma. METHODS A systematic review of recent literature was performed, with the intention of analysing only original research articles focusing on at least two imaging modalities or clinical decision guidelines in relation to blunt force trauma injuries involving the cervical spine. The search used the following databases: ProQuest Central, ScienceDirect, and Scopus. A total of 18 studies were identified as suitable for review; these were further supported by relevant secondary studies. RESULTS It was found that the National Emergency X-Radiology Utilization Study and the Canadian C-Spine Rule are both highly sensitive methods for screening patients after cervical spine injuries. CT was shown to have a higher validity than plain radiography and MRI for the detection of a bony cervical spine injury. MRI is recommended for obtunded or unevaluable patients with suspected neurologic deficit. CONCLUSIONS Overall, the literature appears to suggest that individuals with a suspected high risk of injury after examination using clinical decision rules should undergo a cervical CT examination. For patients who are found to have a low risk of injury after clinical decision guidelines, good-quality plain radiography is recommended as sufficient.
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Affiliation(s)
- Lucy McCutcheon
- Medical Image Optimisation and Perception Group, Discipline of Medical Radiation Sciences, The University of Sydney, Lidcombe, Australia
| | - Nicole Schmocker
- Medical Image Optimisation and Perception Group, Discipline of Medical Radiation Sciences, The University of Sydney, Lidcombe, Australia
| | - Kayla Blanksby
- Medical Image Optimisation and Perception Group, Discipline of Medical Radiation Sciences, The University of Sydney, Lidcombe, Australia
| | - Karishma Bhandary
- Medical Image Optimisation and Perception Group, Discipline of Medical Radiation Sciences, The University of Sydney, Lidcombe, Australia
| | - Benjamin Deacon
- Medical Image Optimisation and Perception Group, Discipline of Medical Radiation Sciences, The University of Sydney, Lidcombe, Australia
| | - Warren Reed
- Medical Image Optimisation and Perception Group, Discipline of Medical Radiation Sciences, The University of Sydney, Lidcombe, Australia.
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Malagelada F, Tibrewal S, Lucar GA, Jeyaseelan L, Fahmy A, Gonzalez JS. Combined Type II Odontoid Fracture With Axis Anterior Arch Fracture: A Case Report in an Elderly Patient. Geriatr Orthop Surg Rehabil 2015; 6:37-41. [PMID: 26246952 PMCID: PMC4318804 DOI: 10.1177/2151458514554083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Associated fractures of the atlas and axis are frequent, particularly in the elderly patients following a simple low-energy fall. This injury can be easily misdiagnosed on initial plain radiographs, and therefore computed tomography scan is a useful adjunct in patients with a degenerative spine. There is still no consensus as to the optimal treatment of combined axis-atlas fractures, and the majority of authors propose a therapeutic strategy dependent on the odontoid fracture pattern. We describe a combined atlas and axis fracture in a 92-year-old patient who was managed with nonoperative treatment in a rigid collar. The association of C1 anterior arch with a C2 type II odontoid fracture is a rare combination, which to our knowledge has never been reported following nonoperative treatment. There was a good functional outcome at 1-year follow-up with the fracture progressing to a fibrous nonunion of the odontoid process.
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Affiliation(s)
- Francesc Malagelada
- Department of Orhtopaedic and Trauma Surgery, Hospital de Mataró, Mataró, Barcelona, Spain
| | - Saket Tibrewal
- Department of Orthopaedics, The Royal London Hospital, London, United Kingdom
| | - Gustavo A. Lucar
- Department of Orhtopaedic and Trauma Surgery, Hospital de Mataró, Mataró, Barcelona, Spain
| | | | - Amr Fahmy
- Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Jose Sanchez Gonzalez
- Department of Orhtopaedic and Trauma Surgery, Hospital de Mataró, Mataró, Barcelona, Spain
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