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Tavender E, Eapen N, Wang J, Rausa VC, Babl FE, Phillips N. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev 2024; 3:CD011686. [PMID: 38517085 PMCID: PMC10958760 DOI: 10.1002/14651858.cd011686.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.
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Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Nitaa Eapen
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Vanessa C Rausa
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Australia
- Biomechanics and Spine Research Group, Centre for Children's Health Research, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Australia
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Picetti E, Demetriades AK, Catena F, Aarabi B, Abu-Zidan FM, Alves OL, Ansaloni L, Armonda RA, Badenes R, Bala M, Balogh ZJ, Barbanera A, Bertuccio A, Biffl WL, Bouzat P, Buki A, Castano-Leon AM, Cerasti D, Citerio G, Coccolini F, Coimbra R, Coniglio C, Costa F, De Iure F, Depreitere B, Fainardi E, Fehlings MJ, Gabrovsky N, Godoy DA, Gruen P, Gupta D, Hawryluk GWJ, Helbok R, Hossain I, Hutchinson PJ, Iaccarino C, Inaba K, Ivanov M, Kaprovoy S, Kirkpatrick AW, Klein S, Kolias A, Konovalov NA, Lagares A, Lippa L, Loza-Gomez A, Luoto TM, Maas AIR, Maciejczak A, Maier RV, Marklund N, Martin MJ, Melloni I, Mendoza-Lattes S, Meyfroidt G, Munari M, Napolitano LM, Okonkwo DO, Otomo Y, Papadopoulos MC, Petr O, Peul WC, Pudkrong AK, Qasim Z, Rasulo F, Reizinho C, Ringel F, Rizoli S, Rostami E, Rubiano AM, Russo E, Sarwal A, Schwab JM, Servadei F, Sharma D, Sharif S, Shiban E, Shutter L, Stahel PF, Taccone FS, Terpolilli NA, Thomé C, Toth P, Tsitsopoulos PP, Udy A, Vaccaro AR, Varon AJ, Vavilala MS, Younsi A, Zackova M, Zoerle T, Robba C. Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS). World J Emerg Surg 2024; 19:4. [PMID: 38238783 PMCID: PMC10795357 DOI: 10.1186/s13017-023-00525-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 11/25/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. METHODS A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. RESULTS A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). CONCLUSIONS This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy.
| | - Andreas K Demetriades
- Department of Neurosurgery, Royal Infirmary Edinburgh, Edinburgh, UK
- Leiden University Neurosurgical Centre Holland, HMC-HAGA The Hague & LUMC Leiden, Leiden, The Netherlands
| | - Fausto Catena
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Oscar L Alves
- Hospital Lusíadas Porto, Centro Hospitalar de Gaia/Espinho, Porto, Portugal
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, Pavia, Italy
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - Miklosh Bala
- Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Andrea Barbanera
- Department of Neurosurgery, SS Antonio e Biagio e Cesare Arrigo Alessandria Hospital, Alessandria, Italy
| | - Alessandro Bertuccio
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Pierre Bouzat
- Universite Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Andras Buki
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | | | - Davide Cerasti
- Neuroradiology Unit, Parma University Hospital, Parma, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Neuroscience, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Division of Trauma and Acute Care Surgery, Riverside University Health System Medical Center, Riverside, CA, USA
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Francesco Costa
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy
| | - Federico De Iure
- Department of Spine Surgery, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Louvain, Belgium
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Michael J Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, ON, Canada
| | - Nikolay Gabrovsky
- Clinic of Neurosurgery, University Hospital Pirogov, Sofia, Bulgaria
| | | | - Peter Gruen
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Gregory W J Hawryluk
- Neurological Institute, Cleveland Clinic, Akron General Hospital, Fairlawn, OH, USA
| | - Raimund Helbok
- Department of Neurology, Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Corrado Iaccarino
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Marcel Ivanov
- Neurosurgery Department, Royal Hallamshire Hospital, Sheffield, UK
| | - Stanislav Kaprovoy
- Department of Spinal and Peripheral Nerve Surgery Burdenko Neurosurgical Center, Moscow, Russia
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Sam Klein
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- ANAPLASI Rehabilitation Centre, Athens, Greece
- 1St Neurosurgery Department, Henry Dunant Hospital Center, Athens, Greece
| | - Nikolay A Konovalov
- Department of Spinal and Peripheral Nerve Surgery Burdenko Neurosurgical Center, Moscow, Russia
| | - Alfonso Lagares
- Neurosurgery Department, University Hospital "12 de Octubre", Madrid, Spain
| | - Laura Lippa
- Department of Neurosurgery, Ospedale Niguarda, Milan, Italy
| | - Angelica Loza-Gomez
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Andrzej Maciejczak
- Department of Neurosurgery, St Luke Hospital, University of Rzeszow, Tarnow, Poland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | | | - Ilaria Melloni
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Louvain, Belgium
| | - Marina Munari
- Neuro-Intensive Care Unit, University Hospital of Padova, Padua, Italy
| | - Lena M Napolitano
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Wilco C Peul
- Leiden University Neurosurgical Centre Holland, HMC-HAGA The Hague & LUMC Leiden, Leiden, The Netherlands
| | - Aichholz K Pudkrong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Zaffer Qasim
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frank Rasulo
- Department of Neuroanesthesia and Neurocritical Care, Spedali Civili University Affiliated Hospital of Brescia, Brescia, Italy
| | - Carla Reizinho
- Departamento de Neurocirurgia, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Florian Ringel
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Sandro Rizoli
- Trauma Surgery Department, Hamad General Hospital, HMC, Doha, Qatar
| | - Elham Rostami
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Emanuele Russo
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Cesena, Italy
| | - Aarti Sarwal
- Department of Neurology, Atrium Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jan M Schwab
- Belford Center for Spinal Cord Injury and Departments of Neurology and Neuroscience, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Franco Servadei
- Humanitas Research Hospital-IRCCS & Humanitas University, Rozzano, Milan, Italy
| | - Deepak Sharma
- Neuroanesthesia & Perioperative Neuroscience, University of Washington, Seattle, WA, USA
| | - Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital, Karachi, Pakistan
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Fabio S Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Nicole A Terpolilli
- Department of Neurosurgery, LMU Hospital, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Peter Toth
- Department of Neurosurgery, Medical School, University of Pecs, Pecs, Hungary
| | - Parmenion P Tsitsopoulos
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloníki, Greece
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, 3004, Australia
| | - Alexander R Vaccaro
- Department of Orthopedic Surgery, Delaware Valley Spinal Cord Injury Center, Rothman Orthopedics, Sidney Kimmel Medical Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Albert J Varon
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine/Ryder Trauma Center, Miami, FL, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Monika Zackova
- Division of Intensive Care and Neurology Unit, Montecatone Rehabilitation Institute, Imola, Italy
| | - Tommaso Zoerle
- Department of Pathophysiology and Transplantation, University of Milan, Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Robba
- IRCCS Policlinico San Martino, Dipartimento di Scienze Chirurgiche Diagnostiche e Integrate, Università di Genova, Genoa, Italy
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Rajchagool B, Pattanakuhar S. Intractable postural hypotension resulting from cervical pseudomeningocele after a posterior cervical spinal surgery: a case report. Spinal Cord Ser Cases 2023; 9:14. [PMID: 37029124 PMCID: PMC10082036 DOI: 10.1038/s41394-023-00572-8] [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: 12/09/2022] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/09/2023] Open
Abstract
INTRODUCTION Postural hypotension (PH) is common in patients with spinal cord injury (SCI), especially those with tetraplegia. To effectively treat PH, identifying and eliminating treatable predisposing factors of PH are prerequisites before applying any interventions. CASE PRESENTATION We report a patient with post-acute cervical SCI who suffered from intractable PH resulting from pseudomeningocele causing unfavorable rehabilitation outcomes. A previously healthy 34-year-old man with complete C6 SCI resulting from C6-C7 fracture dislocation developed PH in the first week of the rehabilitation program. No specific predisposing factors including anemia, hyponatremia, and dehydration were identified. Non-pharmacological interventions and pharmacological treatment were administered to the patient without satisfactory result, causing a delay in rehabilitation progression. In the fourth week of rehabilitation program, a mass at the surgical site was detected. A cervical MRI revealed a large fluid collection at the posterior aspect of cervical spines with a size of 7.9 × 6.8 × 5.0 cm. A diagnosis of pseudomeningocele was made and surgical site debridement with closing dura by grafting was immediately conducted. One day after surgery, PH disappeared, and the patient could progress in his rehabilitation program and achieve his short-term goal within three weeks. CONCLUSION Pseudomeningocele could be one of the precipitating factors of PH in patients with tetraplegia. Healthcare providers should consider investigating pseudomeningocele in patients who have intractable and unexplainable PH.
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Affiliation(s)
- Buddharaksa Rajchagool
- Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sintip Pattanakuhar
- Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
- Health Services and Clinical Care Research Group, Swiss Paraplegic Research, Nottwil, Switzerland.
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Cervical spine injury: clinical and medico-legal overview. LA RADIOLOGIA MEDICA 2023; 128:103-112. [PMID: 36719553 PMCID: PMC9931800 DOI: 10.1007/s11547-022-01578-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 12/07/2022] [Indexed: 02/01/2023]
Abstract
Spinal trauma is an important cause of disability worldwide. Injury to the cervical spine (CS) occurs frequently after major trauma. 5-10% of patients with blunt trauma have a cervical spine injury. The cervical spine accounts for ~ 50% of all spinal injuries. Determination of CS stability is a common challenge in the acute care setting of patients with trauma. Several issues, indeed, are of particular concern: who needs CS imaging; what imaging should be obtained; when should computed tomography (CT), magnetic resonance imaging (MRI), or flexion/extension (F/E) radiographs be obtained; and how is significant ligamentous injury excluded in the comatose patient. CT and MRI both have roles to play. This article aims to present the different imaging to frame techniques to be used with greater precision in the acute event also for the purpose of planning the next therapeutic process. An overview of the applicability of the same methods in forensic pathology is also provided highlighting possible future biomarker to ease in diagnosis of acute TBI.
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Nagi MAMA, Sakr MMS. Accuracy of MRI (TLICS vs AOSIS) in assessment of thoracolumbar spine injuries for guiding treatment. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00715-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The thoracic segment represents the most common area fractured in the whole spine. Complete neurological deficits are commonly associated with thoracic injuries possibly due to a relatively small canal diameter as compared to the cervical or lumbar spine. Magnetic resonance is the gold standard of imaging, especially in patients suffering from neurological deficits as well as in soft tissue assessment mainly the disc, ligaments, and neural elements. The thoracolumbar injury classification and severity score system (TLICS) and the thoracolumbar AO Spine injury score (TLAOSIS), are two scoring systems designed to help surgeons in management plans of thoraco-lumbar injuries. The aim of our study is to compare these two main thoracolumbar injury classification systems in deciding the management strategies in thoraco-lumbar injuries. This study is a retrospective study that included 70 patients (42 males and 28 females) who suffered acute traumatic vertebral fractures. All patients underwent MRI including T1WI, T2W and STIR sequences. The MRI was viewed by two independent radiologists of 5- and 10-years’ experience and compared to surgical decisions.
Results
Out of 70 patients included in our study, the TL AOSIS matched treatment recommendation in 62 patients (88.6%), and the TLICS matched in 60 patients (85.7%). The TL AOSIS achieved sensitivity 95%, specificity 80%, while the TLICS achieved sensitivity 72.2%, specificity 100%.
Conclusion
Both TL AOSIS and TLICS have very close results in their reliability for guiding treatment strategy, yet TL AOSIS matched treatment recommendation more than TLICS, with sensitivity more than TLICS, while TLICS had more specificity.
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Furlan D, Deana C, Orso D, Licari M, Cappelletto B, DE Monte A, Vetrugno L, Bove T. Perioperative management of spinal cord injury: the anesthesiologist's point of view. Minerva Anestesiol 2021; 87:1347-1358. [PMID: 34874136 DOI: 10.23736/s0375-9393.21.15753-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) is one of the most devastating events a person can experience. It may be life-threatening or result in long-term disability. This narrative review aims to delineate a systematic step-wise airways, breathing, circulation and disability (ABCD) approach to perioperative patient management during spinal cord surgery in order to fill some of the gaps in our current knowledge. METHODS We performed a comprehensive review of the literature regarding the perioperative management of traumatic spinal injuries from May 15, 2020, to December 13, 2020. We consulted the PubMed and Embase database libraries. RESULTS Videolaryngoscopy supplements the armamentarium available for airway management. Optical fiberscope use should be evaluated when intubating awake patients. Respiratory complications are frequent in the acute phase of traumatic spinal injury, with an estimated incidence of 36-83%. Early tracheostomy can be considered for expected difficult weaning from mechanical ventilation. Careful intraoperative management of administered fluids should be pursued to avoid complications from volume overload. Neuromonitoring requires investments in staff training and cooperation, but better outcomes have been obtained in centers where it is routinely applied. The prone position can cause rare but devastating complications, such as ischemic optic neuropathy; thus, the anesthetist should take the utmost care in positioning the patient. CONCLUSIONS A one-size fit all approach to spinal surgery patients is not applicable due to patient heterogeneity and the complexity of the procedures involved. The neurologic outcome of spinal surgery can be improved, and the incidence of complications reduced with better knowledge of patient-specific aspects and individualized perioperative management.
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Affiliation(s)
- Davide Furlan
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Daniele Orso
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Maurizia Licari
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Barbara Cappelletto
- Section of Spine and Spinal Cord Surgery, Department of Neurological Sciences, ASUFC University Hospital of Udine, Udine, Italy
| | - Amato DE Monte
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Medicine (DAME), University of Udine, Udine, Italy - .,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Department of Medicine (DAME), University of Udine, Udine, Italy.,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
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The Role of Magnetic Resonance Imaging to Inform Clinical Decision-Making in Acute Spinal Cord Injury: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10214948. [PMID: 34768468 PMCID: PMC8584859 DOI: 10.3390/jcm10214948] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022] Open
Abstract
The clinical indications and added value of obtaining MRI in the acute phase of spinal cord injury (SCI) remain controversial. This review aims to critically evaluate evidence regarding the role of MRI to influence decision-making and outcomes in acute SCI. A systematic review and meta-analysis were performed according to PRISMA methodology to identify studies that address six key questions (KQs) regarding diagnostic accuracy, frequency of abnormal findings, frequency of altered decision-making, optimal timing, and differences in outcomes related to obtaining an MRI in acute SCI. A total of 32 studies were identified that addressed one or more KQs. MRI showed no adverse events in 156 patients (five studies) and frequently identified cord compression (70%, 12 studies), disc herniation (43%, 16 studies), ligamentous injury (39%, 13 studies), and epidural hematoma (10%, two studies), with good diagnostic accuracy (seven comparative studies) except for fracture detection. MRI findings often altered management, including timing of surgery (78%, three studies), decision to operate (36%, 15 studies), and surgical approach (29%, nine studies). MRI may also be useful to determine the need for instrumentation (100%, one study), which levels to decompress (100%, one study), and if reoperation is needed (34%, two studies). The available literature consistently concluded that MRI was useful prior to surgical treatment (13 studies) and after surgery to assess decompression (two studies), but utility before/after closed reduction of cervical dislocations was unclear (three studies). One study showed improved outcomes with an MRI-based protocol but had a high risk of bias. Heterogeneity was high for most findings (I2 > 0.75). MRI is safe and frequently identifies findings alter clinical management in acute SCI, although direct evidence of its impact on outcomes is lacking. MRI should be performed before and after surgery, when feasible, to facilitate improved clinical decision-making. However, further research is needed to determine its optimal timing, effect on outcomes, cost-effectiveness, and utility before and after closed reduction.
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Abstract
In the evaluation of spinal trauma, diagnostic imaging is of paramount importance. Computed tomography (CT), flexion/extension radiographs, and MRI are complementary modalities. CT is typically obtained in the initial setting of spinal trauma and provides detailed information about osseous structures. MRI provides detailed information about structural injury to the spinal cord. Diffusion tensor imaging provides microstructural information about the integrity of the axons and myelin sheaths, but its clinical use is limited. Novel imaging techniques may be better suited for the acute clinical setting and are under development for potential future clinical use.
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9
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Breton JM, George KM, Riesenburger RI. Diagnosis of a chronic spinal cord injury via televisit in a patient from an underserved community. J Surg Case Rep 2021; 2021:rjab090. [PMID: 33927849 PMCID: PMC8055214 DOI: 10.1093/jscr/rjab090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
A 42-year-old woman from a medically underserved community in rural New England was referred by her primary care provider (PCP) for televisit during the coronavirus disease 2019 (COVID-19) pandemic following 2 years of chronic neck pain and numbness in her left hand that was initially concerning for demyelinating disease. Upon further evaluation, it was revealed that she had experienced a traumatic fall with a concussion and symptoms consistent with central cord syndrome but had refused magnetic resonance imaging (MRI) at her initial medical evaluation. On MRI conducted 1 month prior to neurosurgical evaluation she was found to have a disc bulge and 4-mm T2-hyperintense lesion at the C4–C5 level that was consistent with a chronic spinal cord injury secondary to spinal trauma with associated vertebrogenic injury. This televisit confirmed the diagnosis of chronic spinal cord injury for this patient and allowed for discussion of future interventions, avoided further unnecessary referrals, and increased access to care.
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Affiliation(s)
- Jeffrey M Breton
- Department of Neurosurgery, Tufts University School of Medicine, Boston, MA, USA
| | - Keith M George
- Department of Neurosurgery, Tufts University School of Medicine, Boston, MA, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts University School of Medicine, Boston, MA, USA
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10
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Guo X, Feng Y, Sun T, Feng S, Tang J, Chen L, Cao X, Lin H, He X, Li M, Zhang Z, Yin G, Mei X, Huang H. Clinical guidelines for neurorestorative therapies in spinal cord injury (2021 China version). JOURNAL OF NEURORESTORATOLOGY 2021. [DOI: 10.26599/jnr.2021.9040003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Treatment of spinal cord injury (SCI) remains challenging. Considering the rapid developments in neurorestorative therapies for SCI, we have revised and updated the Clinical Therapeutic Guidelines for Neurorestoration in Spinal Cord Injury (2016 Chinese version) of the Chinese Association of Neurorestoratology (Preparatory) and China Committee of International Association of Neurorestoratology. Treatment of SCI is a systematic multimodal process that aims to improve survival and restore neurological function. These guidelines cover real-world comprehensive neurorestorative management of acute, subacute, and chronic SCI and include assessment and diagnosis, pre-hospital first aid, treatment, rehabilitation, and complication management.
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11
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Garg B, Ahuja K. C-spine clearance in poly-trauma patients: A narrative review. J Clin Orthop Trauma 2021; 12:66-71. [PMID: 33716430 PMCID: PMC7920196 DOI: 10.1016/j.jcot.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/26/2022] Open
Abstract
The incidence of cervical spine injury in patients with polytrauma is 3.7%. Early identification and management of cervical spine injuries in these patients play a crucial role in preventing secondary cervical spine and cord injuries. C-spine clearance assumes a pivotal role in reducing the morbidity and mortality associated with cervical spine injury. Despite the availability of various validated management algorithms and protocols for C-spine clearance, there are several controversies regarding C-spine clearance, such as the ideal protocol and imaging modality, clearance of obtunded patients and management of patients that lie out of the described protocols and rules. The current article aims to provide a comprehensive review of the relevant literature and address the prevalent controversies.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Kaustubh Ahuja
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, 249203, Uttarakhand, India
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12
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Maeda K, Ichiba T. Unusual Clinical Course of Odontoid Fracture: Transient Prehospital Cardiopulmonary Arrest. Cureus 2020; 12:e12157. [PMID: 33489569 PMCID: PMC7813530 DOI: 10.7759/cureus.12157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Odontoid fracture is the most common type of cervical spine fracture in the elderly. Neurological injury due to odontoid fracture is uncommon, but if the injury is severe, it can lead to cardiac arrest. We present a case of odontoid fracture with transient cardiac arrest just after the fall, which fully recovered in a few minutes before arrival at the hospital. A 62-year-old man fell down on a street, and compressions were performed by a witness. On arrival of the emergency medical service, he showed pulseless electrical activity. After two minutes of cardiac resuscitation, he experienced a return of spontaneous circulation and was breathing spontaneously. On arrival at our hospital, his blood pressure was 171/106 mmHg, heart rate was 100 beats per minute, and respiratory rate was 12 times per minute, but he was at Glasgow Coma Scale 3 with an alcohol odor from exhaled breath. Six hours after admission, his level of consciousness improved, and he complained of neck pain and difficulty in movement of his arms and legs. CT revealed a fracture and posteriorly displaced C2 bone. MRI showed a hyper-intense area from C1 to C2. We made a diagnosis of spinal cord injury caused by an odontoid fracture that led to cardiac arrest. An odontoid fracture can cause transient cardiac arrest just after a fall. The possibility of odontoid fracture associated cervical spine injury should be considered in elderly and unconscious patients with minor trauma. Early CT cervical spine in selected patients can be helpful, especially in patients with cardiac arrest, even if it lasted for only a short prehospital period.
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13
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Abdul Azeez MM, Moscote-Salazar LR, Alcala-Cerra G, García-Ballestas E, Bustos-Salazar D, Satyarthee GD, Agrawal A. Emergency Management of Traumatic Spinal Cord Injuries. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractSpinal cord trauma constitutes one of the main causes of mortality and morbidity in young adults around the world, with an estimated 2 to 3 new cases for every 100,000 population. Road traffic accidents, falls from high heights, sports injuries, and violent actions are common causes of spinal cord injuries. There is no “gold standard” for the diagnosis of spinal cord traumatic injuries; however, the rational use of conventional radiologic test, computed tomography scan, and magnetic resonance imaging (MRI) will allow to identify almost all clinically relevant injuries. MRI is recommended according to surgeon’s criteria, who after evaluating the specific characteristics of the injury will determine its usefulness. Therapeutic strategies need to be directed to maintain airway, breathing and circulation, maintenance of mean arterial pressure prevention of hypotension, and assessment of other associated injuries. Intensive treatment must be focused on the prevention and management of ventilatory and cardiovascular abnormalities related to muscle weakness and loss of autonomic innervation.
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Affiliation(s)
| | - Luis Rafael Moscote-Salazar
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia
- Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Gabriel Alcala-Cerra
- Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Ezequiel García-Ballestas
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia
- Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Diego Bustos-Salazar
- Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Guru Dutta Satyarthee
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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14
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Giuseppe G, Ilaria M, Federico D, Alessandro C, Simona G, Nazerian P, Marco B, Stefano G. Severe thoracic or abdominal injury in major trauma patients can safely be ruled out by "Valutazione Integrata Bed Side" evaluation without total body CT scan. Ir J Med Sci 2020; 190:799-805. [PMID: 32888166 DOI: 10.1007/s11845-020-02351-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND During the initial assessment of trauma patients, the severity of injury is very often not immediately recognizable. In trauma centers, a total body CT (TBCT) scan is routinely used to evaluate this kind of patients, even if it is burdened with health risk, economical costs, and logistical difficulties. AIM We investigated the use of a clinical guide to establish a safe alternative to this routine practice. METHODS We enrolled retrospectively 438 patients referring to the Emergency Department of Careggi University Hospital in Florence (Italy) over a 1-year period from 2014 to 2015, with the evidence of trauma and high-priority triage codes and then subjected to TBCT. We created a tool called VIBS ("Valutazione Integrata Bed Side") (from the Italian translation of "Bed Side Integrated Evaluation") which included all clinical, laboratory, and diagnostic data acquired bedside during the primary survey. Every VIBS profile was dichotomized in negative or positive if there was at least one altered item. We performed an analysis of correlation between VIBS and TBCT to determine sensibility, specificity, positive, and negative predictive value and likelihood ratio of VIBS. RESULTS Sensibility of VIBS in the prediction of positive CT scan was 100% and specificity was 31.7%. Positive and negative predictive value (95% C.I.) was 44.3 (38.8-49.5) and 100 (94.0-99.9). Positive and negative likelihood ratios were 1.464 and 0. Failure rate resulted in 0% and efficiency was 20.54%. CONCLUSIONS VIBS can safely rule out severe thoracic or abdominal injuries. This approach could limit the use of TBCT in one-fifth of suspected major trauma patients.
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Affiliation(s)
| | - Melara Ilaria
- Emergency Medicine Fellowship Program, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | | | - Coppa Alessandro
- Department of Emergency Medicine, S.Giuseppe Hospital, Empoli, Italy
| | | | | | - Bartolini Marco
- Department of Radiology, Careggi University Hospital, Florence, Italy
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16
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Abstract
Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last three decades, there have been considerable advancements in the management of patients with traumatic SCI. The advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit (ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.
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17
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Shank CD, Lepard JR, Walters BC, Hadley MN. Towards Evidence-Based Guidelines in Neurological Surgery. Neurosurgery 2019; 85:613-621. [PMID: 30239922 DOI: 10.1093/neuros/nyy414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 08/03/2018] [Indexed: 11/15/2022] Open
Abstract
Neurological surgery practice is based on the science of balancing probabilities. A variety of clinical guidance documents have influenced how we collectively practice our art since the early 20th century. The quality of the science within these guidelines varies widely, as does their utility in positively shaping our practice. The guidelines development process in neurological surgery has evolved significantly over the last 30 yr. Historically based in expert opinion, as a specialty we have increasingly relied on objective medical evidence to guide our clinical practice. We assessed the changing practice guidelines development process and the impact of scientifically robust guidelines on patient care. The evolution of the guidelines development process in neurological surgery was chronicled. Several subspecialty guidelines were extracted and reviewed in detail. Their impact on practice patterns was evaluated. The importance of evidence-based research and practice guidelines development was discussed. Evidence-based practice guidelines serve to chronicle multiple acceptable treatment options and help us move towards more standardized care for specific disease processes. They help refute false "standards of care." Guidelines-based care supported by solid medical evidence has the potential to streamline patient care and improve patient outcomes. The guidelines development process identifies areas, issues, and strategies for which little medical evidence exists, as well as topics that need focused scientific investigation and future study. The production of evidence-based practice recommendations is a vital part of furthering our specialty. Guidelines development advances our science, augments the resident education process, and protects our practice from undue external influence.
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Affiliation(s)
- Christopher D Shank
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jacob R Lepard
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark N Hadley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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18
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Wu X, Malhotra A, Geng B, Kalra VB, Abbed K, Forman HP, Sanelli P. Cost-effectiveness of Magnetic Resonance Imaging in Cervical Clearance of Obtunded Blunt Trauma After a Normal Computed Tomographic Finding. JAMA Surg 2019. [PMID: 29541757 DOI: 10.1001/jamasurg.2018.0099] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Magnetic resonance imaging (MRI) continues to be performed for cervical clearance of obtunded blunt trauma, despite poor evidence regarding its utility after a normal computed tomographic (CT) finding. Objective To evaluate the utility and cost-effectiveness of MRI vs no follow-up after a normal cervical CT finding in patients with obtunded blunt trauma. Design, Setting and Participants This cost-effectiveness analysis evaluated an average patient aged 40 years with blunt trauma from an institutional practice. The analysis used a Markov decision model over a lifetime horizon from a societal perspective with variables from systematic reviews and meta-analyses and reimbursement rates from the Centers for Medicare & Medicaid Services, National Spinal Cord Injury Database, and other large published studies. Data were collected from the most recent literature available. Interventions No follow-up vs MRI follow-up after a normal cervical CT finding. Results In the base case of a 40-year-old patient, the cost of MRI follow-up was $14 185 with a health benefit of 24.02 quality-adjusted life-years (QALY); the cost of no follow-up was $1059 with a health benefit of 24.11 QALY, and thus no follow-up was the dominant strategy. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10 000 iterations. No follow-up was the better strategy when the negative predictive value of the initial CT was relatively high (>98%) or the risk of an injury treated with a cervical collar turning into a permanent neurologic deficit was higher than 25% or when the risk of a missed injury turning into a neurologic deficit was less than 58%. The sensitivity and specificity of MRI were varied simultaneously in a 2-way sensitivity analysis, and no follow-up remained the optimal strategy. Conclusions and Relevance Magnetic resonance imaging had a lower health benefit and a higher cost compared with no follow-up after a normal CT finding in patients with obtunded blunt trauma to the cervical spine, a finding that does not support the use of MRI in this group of patients. The conclusion is robust in sensitivity analyses varying key variables in the model. More literature on these key variables is needed before MRI can be considered to be beneficial in the evaluation of obtunded blunt trauma.
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Affiliation(s)
- Xiao Wu
- currently a medical student at Yale School of Medicine, New Haven, Connecticut
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Bertie Geng
- currently a medical student at Yale School of Medicine, New Haven, Connecticut
| | - Vivek B Kalra
- Department of Radiology, Orlando Health, Orlando, Florida
| | - Khalid Abbed
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut.,Department of Economics, Yale School of Medicine, New Haven, Connecticut.,Department of Management, Yale School of Medicine, New Haven, Connecticut.,Department of Public Health, Yale School of Medicine, New Haven, Connecticut
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York
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Hadley MN, Walters BC. The case for the future role of evidence-based medicine in the management of cervical spine injuries, with or without fractures. J Neurosurg Spine 2019; 31:457-463. [PMID: 31574462 DOI: 10.3171/2019.6.spine19652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/19/2019] [Indexed: 11/06/2022]
Abstract
The authors believe that the standardized and systematic study of immobilization techniques, diagnostic modalities, medical and surgical treatment strategies, and ultimately outcomes and outcome measurement after cervical spinal trauma and cervical spinal fracture injuries, if performed using well-designed medical evidence-based comparative investigations with meaningful follow-up, has both merit and the remarkable potential to identify optimal strategies for assessment, characterization, and clinical management. However, they recognize that there is inherent difficulty in attempting to apply evidence-based medicine (EBM) to identify ideal treatment strategies for individual cervical fracture injuries. First, there is almost no medical evidence reported in the literature for the management of specific isolated cervical fracture subtypes; specific treatment strategies for specific fracture injuries have not been routinely studied in a rigorous, comparative way. One of the vulnerabilities of an evidenced-based scientific review in spinal cord injury (SCI) is the lack of studies in comparative populations and scientific evidence on a given topic or fracture pattern providing level II evidence or higher. Second, many modest fracture injuries are not associated with vascular or neural injury or spinal instability. The application of the science of EBM to the care of patients with traumatic cervical spine injuries and SCIs is invaluable and necessary. The dedicated multispecialty author groups involved in the production and publication of the two iterations of evidence-based guidelines on the management of acute cervical spine and spinal cord injuries have provided strategic guidance in the care of patients with SCIs. This dedicated service to the specialty has been carried out to provide neurosurgical colleagues with a qualitative review of the evidence supporting various aspects of care of these patients. It is important to state and essential to understand that the science of EBM and its rigorous application is important to medicine and to the specialty of neurosurgery. It should be embraced and used to drive and shape investigations of the management and treatment strategies offered patients. It should not be abandoned because it is not convenient or it does not support popular practice bias or patterns. It is the authors' view that the science of EBM is essential and necessary and, furthermore, that it has great potential as clinician scientists treat and study the many variations and complexities of patients who sustain acute cervical spine fracture injuries.
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Affiliation(s)
- Mark N Hadley
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Beverly C Walters
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
- 2Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
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Sacino A, Rosenblatt K. Early Management of Acute Spinal Cord Injury-Part I: Initial Injury to Surgery. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2019; 6:213-221. [PMID: 34012997 DOI: 10.1055/s-0039-1694688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Acute spinal cord injury is a devastating event associated with substantial morbidity worldwide. The pathophysiology of spinal cord injury involves the initial mechanical trauma and the subsequent inflammatory response, which may worsen the severity of neurologic dysfunction. Interventions have been studied to reduce the extent of primary injury to the spinal cord through preventive measures and to mitigate secondary insult through early specialized care. Management, therefore, is multifold, interdisciplinary, and begins immediately at the time of injury. It includes the trauma triage, acute management of the circulatory and respiratory systems, and definitive treatment, mainly with surgical decompression and stabilization.
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Affiliation(s)
- Amanda Sacino
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Kathryn Rosenblatt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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21
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Radiological protocol in spinal trauma: literature review and Spinal Cord Society position statement. 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 2019; 29:1197-1211. [PMID: 31440893 DOI: 10.1007/s00586-019-06112-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 06/29/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The Spinal Cord Society constituted a panel tasked with reviewing the literature on the radiological evaluation of spinal trauma with or without spinal cord injury and recommend a protocol. This position statement provides recommendations for the use of each modality, i.e., radiographs (X-rays), computed tomography (CT), magnetic resonance imaging (MRI), as well as vascular imaging, and makes suggestions on identifying or clearing spinal injury in trauma patients. METHODS PubMed was searched for the corresponding keywords from January 1, 1980, to August 1, 2017. A MEDLINE search was subsequently undertaken after applying MeSH filters. Appropriate cross-references were retrieved. Out of the 545 articles retrieved, 105 relevant papers that address the present topic were studied and the extracted content was circulated for further discussions. A draft position statement was compiled and circulated among the panel members via e-mail. The draft was modified by incorporating relevant suggestions to reach a consensus. RESULTS AND CONCLUSION For imaging cervical and thoracolumbar spine trauma patients, CT without contrast is generally considered to be the initial line of imaging and radiographs are required if CT is unavailable or unaffordable. CT screening in polytrauma cases is best done with a multidetector CT by utilizing the reformatted images obtained when scanning the chest, abdomen, and pelvis (CT-CAP). MRI is indicated in cases with neurological involvement and advanced cervical degenerative changes and to determine the extent of soft tissue injury, i.e., disco-ligamentous injuries as well as epidural space compromise. MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology. These slides can be retrieved under Electronic Supplementary Material.
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22
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Cizkova D, Murgoci AN, Cubinkova V, Humenik F, Mojzisova Z, Maloveska M, Cizek M, Fournier I, Salzet M. Spinal Cord Injury: Animal Models, Imaging Tools and the Treatment Strategies. Neurochem Res 2019; 45:134-143. [PMID: 31006093 DOI: 10.1007/s11064-019-02800-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 02/06/2023]
Abstract
Spinal cord injury (SCI) often leads to irreversible neuro-degenerative changes with life-long consequences. While there is still no effective therapy available, the results of past research have led to improved quality of life for patients suffering from partial or permanent paralysis. In this review we focus on the need, importance and the scientific value of experimental animal models simulating SCI in humans. Furthermore, we highlight modern imaging tools determining the location and extent of spinal cord damage and their contribution to early diagnosis and selection of appropriate treatment. Finally, we focus on available cellular and acellular therapies and novel combinatory approaches with exosomes and active biomaterials. Here we discuss the efficacy and limitations of adult mesenchymal stem cells which can be derived from bone marrow, adipose tissue or umbilical cord blood and its Wharton's jelly. Special attention is paid to stem cell-derived exosomes and smart biomaterials due to their special properties as a delivery system for proteins, bioactive molecules or even genetic material.
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Affiliation(s)
- Dasa Cizkova
- Institute of Neuroimmunology, Slovak Academy of Sciences, Dúbravská cesta 9, 845 10, Bratislava, Slovakia. .,Department of Anatomy, Histology and Physiology, University of Veterinary Medicine and Pharmacy in Košice, Komenského 73, 041 81, Kosice, Slovakia. .,Inserm, U-1192-Laboratoire Protéomique, Réponse Inflammatoire et Spectrométrie de Masse-PRISM, Université de Lille, 59000, Lille, France.
| | - Adriana-Natalia Murgoci
- Institute of Neuroimmunology, Slovak Academy of Sciences, Dúbravská cesta 9, 845 10, Bratislava, Slovakia.,Inserm, U-1192-Laboratoire Protéomique, Réponse Inflammatoire et Spectrométrie de Masse-PRISM, Université de Lille, 59000, Lille, France
| | - Veronika Cubinkova
- Institute of Neuroimmunology, Slovak Academy of Sciences, Dúbravská cesta 9, 845 10, Bratislava, Slovakia
| | - Filip Humenik
- Department of Anatomy, Histology and Physiology, University of Veterinary Medicine and Pharmacy in Košice, Komenského 73, 041 81, Kosice, Slovakia
| | - Zuzana Mojzisova
- Department of Anatomy, Histology and Physiology, University of Veterinary Medicine and Pharmacy in Košice, Komenského 73, 041 81, Kosice, Slovakia
| | - Marcela Maloveska
- Department of Anatomy, Histology and Physiology, University of Veterinary Medicine and Pharmacy in Košice, Komenského 73, 041 81, Kosice, Slovakia
| | - Milan Cizek
- Department of Epizootology and Parasitology, University of Veterinary Medicine and Pharmacy in Košice, Komenského 73, 041 81, Kosice, Slovakia
| | - Isabelle Fournier
- Inserm, U-1192-Laboratoire Protéomique, Réponse Inflammatoire et Spectrométrie de Masse-PRISM, Université de Lille, 59000, Lille, France
| | - Michel Salzet
- Inserm, U-1192-Laboratoire Protéomique, Réponse Inflammatoire et Spectrométrie de Masse-PRISM, Université de Lille, 59000, Lille, France
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Veiga JRS, Mitchell K. Cervical spine clearance in the adult obtunded blunt trauma patient: A systematic review. Intensive Crit Care Nurs 2018; 51:57-63. [PMID: 30509691 DOI: 10.1016/j.iccn.2018.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 10/02/2018] [Accepted: 11/05/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND A missed cervical spinal injury could have devastating consequences. Patients with a suspected cervical spinal injury are kept in rigid collars for cervical immobilisation. Prolonged collar use has important clinical implications. A well-defined guideline related to the removal of cervical collars from adult obtunded blunt trauma patients has not been developed. AIM We sought to determine if Magnetic Resonance Imaging offered a definitive benefit over Computer Tomography with respect to patient management. METHOD We searched Ovid Online, EBSCO, NICE Evidence Journals, Medline, PubMED, BNI, CINAHL and Google Scholar as well as the grey literature. Data extraction and synthesis were performed on studies that compared the radiologic findings and clinical outcomes of Computer Tomography scan and Magnetic Resonance Imaging in this patient group. RESULTS There is evidence that supports the safe discontinuation of cervical collar use after a negative multidetector Computer Tomography scan result alone. Magnetic Resonance Imaging may detect a significant number of ligamentous injuries, but such injuries are rarely of clinical significance because they rarely alter clinical management. Its use should be limited to specific circumstances. CONCLUSION It is important for institutions to re-examine the latest evidence regarding cervical spinal clearance in order to update their guidelines.
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Affiliation(s)
| | - Kay Mitchell
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton, Southampton, UK
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24
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Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T. Review article: Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series). Emerg Med Australas 2018; 30:754-772. [PMID: 30168261 DOI: 10.1111/1742-6723.13131] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/14/2018] [Accepted: 06/10/2018] [Indexed: 12/13/2022]
Abstract
Neck pain and whiplash injuries are a common presentation to the ED, and a frequent cause of disability globally. This rapid review investigated best practice for the assessment and management of musculoskeletal neck pain in the ED. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years addressing acute neck pain assessment, management or prognosis in the ED were included. Data extraction was conducted, followed by quality appraisal to rate levels of evidence where possible. The search revealed 2080 articles, of which 51 were included (n = 22 primary articles, n = 13 systematic reviews and n = 16 guidelines). Consistent evidence was found to support the use of 'red flags' to screen for serious pathologies, judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance. Clinicians may also consider applying risk-stratification methods, such as using a clinical prediction rule, to guide patient discharge and referral plans; however, the evidence is still emerging in this population. This rapid review provides clinicians managing neck pain in the ED a summary of the best available evidence to enhance quality of care and optimise patient outcomes.
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Affiliation(s)
- Kirsten Strudwick
- Emergency Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia.,Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia.,School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Megan McPhee
- Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Anthony Bell
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Melinda Martin-Khan
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Trevor Russell
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
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25
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Ahuja CS, Nori S, Tetreault L, Wilson J, Kwon B, Harrop J, Choi D, Fehlings MG. Traumatic Spinal Cord Injury-Repair and Regeneration. Neurosurgery 2017; 80:S9-S22. [PMID: 28350947 DOI: 10.1093/neuros/nyw080] [Citation(s) in RCA: 481] [Impact Index Per Article: 68.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/12/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Traumatic spinal cord injuries (SCI) have devastating consequences for the physical, financial, and psychosocial well-being of patients and their caregivers. Expediently delivering interventions during the early postinjury period can have a tremendous impact on long-term functional recovery. PATHOPHYSIOLOGY This is largely due to the unique pathophysiology of SCI where the initial traumatic insult (primary injury) is followed by a progressive secondary injury cascade characterized by ischemia, proapoptotic signaling, and peripheral inflammatory cell infiltration. Over the subsequent hours, release of proinflammatory cytokines and cytotoxic debris (DNA, ATP, reactive oxygen species) cyclically adds to the harsh postinjury microenvironment. As the lesions mature into the chronic phase, regeneration is severely impeded by the development of an astroglial-fibrous scar surrounding coalesced cystic cavities. Addressing these challenges forms the basis of current and upcoming treatments for SCI. MANAGEMENT This paper discusses the evidence-based management of a patient with SCI while emphasizing the importance of early definitive care. Key neuroprotective therapies are summarized including surgical decompression, methylprednisolone, and blood pressure augmentation. We then review exciting neuroprotective interventions on the cusp of translation such as Riluzole, Minocycline, magnesium, therapeutic hypothermia, and CSF drainage. We also explore the most promising neuroregenerative strategies in trial today including Cethrin™, anti-NOGO antibody, cell-based approaches, and bioengineered biomaterials. Each section provides a working knowledge of the key preclinical and patient trials relevant to clinicians while highlighting the pathophysiologic rationale for the therapies. CONCLUSION We conclude with our perspectives on the future of treatment and research in this rapidly evolving field.
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Affiliation(s)
- Christopher S Ahuja
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Institute of Medical Science, University of Toronto, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada.,Department of Genetics and Development, University of Toronto, Toronto, Canada
| | - Satoshi Nori
- Department of Genetics and Development, University of Toronto, Toronto, Canada
| | | | - Jefferson Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada.,Spine Program, University of Toronto, Toronto, Canada
| | - Brian Kwon
- Vancouver Spine Institute, Vancouver General Hospital, Vancouver, Canada.,Department of Surgery, University of British Columbia, Vancouver, Canada
| | - James Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - David Choi
- National Hospital for Neurology and Neurosurgery, University College London, London, England
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Institute of Medical Science, University of Toronto, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada.,Spine Program, University of Toronto, Toronto, Canada.,Department of Genetics and Development, University of Toronto, Toronto, Canada
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27
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Abstract
Traumatic spinal cord injuries have a tremendous impact on individuals, families, and society as a whole. Substantial heterogeneity in the patient population, their presentation and underlying pathophysiology has sparked debates along the care spectrum from initial assessment to definitive treatment. This article reviews spinal cord injury (SCI) management followed by a discussion of the salient controversies in the field. Current care practices modeled on the American Association of Neurological Surgeons/Congress of Neurological Surgeons joint section guidelines are highlighted including key recommendations regarding immobilization, avoidance of hypotension, early International Standards for Neurological Classification of SCI examination and intensive care unit treatment. From a diagnostic perspective, the evolving roles of CT, MRI, and leading-edge microstructural MRI techniques are discussed with descriptions of the relevant clinical literature for each. Controversies in management relevant to clinicians including the timing of surgical decompression, methylprednisolone administration, blood pressure augmentation, intraoperative electrophysiological monitoring, and the role of surgery in central cord syndrome and pediatric SCI are also covered in detail. Finally, the article concludes with a reflection on clinical trial design tailored to the heterogeneous population of individuals with SCI.
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28
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Kurpad S, Martin AR, Tetreault LA, Fischer DJ, Skelly AC, Mikulis D, Flanders A, Aarabi B, Mroz TE, Tsai EC, Fehlings MG. Impact of Baseline Magnetic Resonance Imaging on Neurologic, Functional, and Safety Outcomes in Patients With Acute Traumatic Spinal Cord Injury. Global Spine J 2017; 7:151S-174S. [PMID: 29164022 PMCID: PMC5684848 DOI: 10.1177/2192568217703666] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To perform a systematic review to evaluate the utility of magnetic resonance imaging (MRI) in patients with acute spinal cord injury (SCI). METHODS An electronic search of Medline, EMBASE, the Cochrane Collaboration Library, and Google Scholar was conducted for literature published through May 12, 2015, to answer key questions associated with the use of MRI in patients with acute SCI. RESULTS The literature search yielded 796 potentially relevant citations, 8 of which were included in this review. One study used MRI in a protocol to decide on early surgical decompression. The MRI-protocol group showed improved outcomes; however, the quality of evidence was deemed very low due to selection bias. Seven studies reported MRI predictors of neurologic or functional outcomes. There was moderate-quality evidence that longer intramedullary hemorrhage (2 studies) and low-quality evidence that smaller spinal canal diameter at the location of maximal spinal cord compression and the presence of cord swelling are associated with poor neurologic recovery. There was moderate-quality evidence that clinical outcomes are not predicted by SCI lesion length and the presence of cord edema. CONCLUSIONS Certain MRI characteristics appear to be predictive of outcomes in acute SCI, including length of intramedullary hemorrhage (moderate-quality evidence), canal diameter at maximal spinal cord compression (low-quality evidence), and spinal cord swelling (low-quality evidence). Other imaging features were either inconsistently (presence of hemorrhage, maximal canal compromise, and edema length) or not associated with outcomes. The paucity of literature highlights the need for well-designed prospective studies.
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Affiliation(s)
| | - Allan R. Martin
- University of Toronto, Toronto, Ontario, Canada,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | | | | | - David Mikulis
- University of Toronto, Toronto, Ontario, Canada,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | | | | | - Eve C. Tsai
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,University of Ottawa, Ottawa, Ontario, Canada
| | - Michael G. Fehlings
- University of Toronto, Toronto, Ontario, Canada,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Michael G. Fehlings, MD, PhD, FRCSC, FACS, Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street (SCI-CRU, 11th Floor McLaughlin Pavilion), Toronto, Ontario M5T 2S8, Canada.
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29
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Fehlings MG, Martin AR, Tetreault LA, Aarabi B, Anderson P, Arnold PM, Brodke D, Burns AS, Chiba K, Dettori JR, Furlan JC, Hawryluk G, Holly LT, Howley S, Jeji T, Kalsi-Ryan S, Kotter M, Kurpad S, Kwon BK, Marino RJ, Massicotte E, Merli G, Middleton JW, Nakashima H, Nagoshi N, Palmieri K, Singh A, Skelly AC, Tsai EC, Vaccaro A, Wilson JR, Yee A, Harrop JS. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role of Baseline Magnetic Resonance Imaging in Clinical Decision Making and Outcome Prediction. Global Spine J 2017; 7:221S-230S. [PMID: 29164028 PMCID: PMC5684845 DOI: 10.1177/2192568217703089] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The objective of this guideline is to outline the role of magnetic resonance imaging (MRI) in clinical decision making and outcome prediction in patients with traumatic spinal cord injury (SCI). METHODS A systematic review of the literature was conducted to address key questions related to the use of MRI in patients with traumatic SCI. This review focused on longitudinal studies that controlled for baseline neurologic status. A multidisciplinary Guideline Development Group (GDG) used this information, their clinical expertise, and patient input to develop recommendations on the use of MRI for SCI patients. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest." RESULTS Based on the limited available evidence and the clinical expertise of the GDG, our recommendations were: (1) "We suggest that MRI be performed in adult patients with acute SCI prior to surgical intervention, when feasible, to facilitate improved clinical decision-making" (quality of evidence, very low) and (2) "We suggest that MRI should be performed in adult patients in the acute period following SCI, before or after surgical intervention, to improve prediction of neurologic outcome" (quality of evidence, low). CONCLUSIONS These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI.
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Affiliation(s)
- Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Michael G. Fehlings, MD, PhD, FRCSC, FACS, Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street (SCI-CRU, 11th Floor McLaughlin Pavilion), Toronto, Ontario M5T 2S8, Canada.
| | - Allan R. Martin
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lindsay A. Tetreault
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- University College Cork, Cork, Ireland
| | | | | | - Paul M. Arnold
- University of Kansas Medical Center, The University of Kansas, Kansas City, KS, USA
| | | | - Anthony S. Burns
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | | | | | - Julio C. Furlan
- University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | | | | | - Susan Howley
- Christopher & Dana Reeve Foundation, Short Hills, NJ, USA
| | - Tara Jeji
- Ontario Neurotrauma Foundation, Toronto, Ontario, Canada
| | | | | | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Eric Massicotte
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Geno Merli
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | | | - Narihito Nagoshi
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Keio University, Keio, Japan
| | | | - Anoushka Singh
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Eve C. Tsai
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Albert Yee
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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30
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Fehlings MG, Tetreault LA, Wilson JR, Kwon BK, Burns AS, Martin AR, Hawryluk G, Harrop JS. A Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope. Global Spine J 2017; 7:84S-94S. [PMID: 29164036 PMCID: PMC5684846 DOI: 10.1177/2192568217703387] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute spinal cord injury (SCI) is a traumatic event that results in disturbances to normal sensory, motor, or autonomic function and ultimately affects a patient's physical, psychological, and social well-being. The management of patients with SCI has drastically evolved over the past century as a result of increasing knowledge on injury mechanisms, disease pathophysiology, and the role of surgery. There still, however, remain controversial areas surrounding available management strategies for the treatment of SCI, including the use of corticosteroids such as methylprednisolone sodium succinate, the optimal timing of surgical intervention, the type and timing of anticoagulation prophylaxis, the role of magnetic resonance imaging, and the type and timing of rehabilitation. This lack of consensus has prevented the standardization of care across treatment centers and among the various disciplines that encounter patients with SCI. The objective of this guideline is to form evidence-based recommendations for these areas of controversy and outline how to best manage patients with SCI. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.
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Affiliation(s)
- Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Lindsay A. Tetreault
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- University College Cork, Cork, Ireland
| | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada
- St Michael’s Hospital, Toronto, Ontario, Canada
| | - Brian K. Kwon
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Allan R. Martin
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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31
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Wu X, Malhotra A, Geng B, Liu R, Abbed K, Forman HP, Sanelli P. Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma. Ann Emerg Med 2017; 71:64-73. [PMID: 28826754 DOI: 10.1016/j.annemergmed.2017.07.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/05/2017] [Accepted: 07/03/2017] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Use of magnetic resonance imaging (MRI) for cervical clearance after a negative cervical computed tomography (CT) scan result in alert patients with blunt trauma who are neurologically intact is not infrequent, despite poor evidence in regard to its utility. The objective of this study is to evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population. METHODS A modeling-based decision analysis was performed during the lifetime of a 40-year-old individual from a societal perspective. The 2 strategies compared were no follow-up and MRI. A Markov model with a 3% discount rate was used with parameters from the literature. Base cases and probabilistic and sensitivity analyses were performed to assess the cost-effectiveness of the strategies. RESULTS The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed. CONCLUSION MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result.
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Affiliation(s)
- Xiao Wu
- Yale School of Medicine, New Haven, CT
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT.
| | | | - Renu Liu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Khalid Abbed
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT; Departments of Economics, Management, and Public Health, Yale School of Medicine, New Haven, CT
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Long Island, NY
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32
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33
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Affiliation(s)
- Alexander E Ropper
- From the Department of Neurosurgery, Baylor College of Medicine, Houston (A.E.R.)
| | - Allan H Ropper
- From the Department of Neurosurgery, Baylor College of Medicine, Houston (A.E.R.)
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34
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Shank CD, Walters BC, Hadley MN. Management of acute traumatic spinal cord injuries. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:275-298. [PMID: 28187803 DOI: 10.1016/b978-0-444-63600-3.00015-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute traumatic spinal cord injury (SCI) is a devastating disease process affecting tens of thousands of people across the USA each year. Despite the increase in primary prevention measures, such as educational programs, motor vehicle speed limits, automobile running lights, and safety technology that includes automobile passive restraint systems and airbags, SCIs continue to carry substantial permanent morbidity and mortality. Medical measures implemented following the initial injury are designed to limit secondary insult to the spinal cord and to stabilize the spinal column in an attempt to decrease devastating sequelae. This chapter is an overview of the contemporary management of an acute traumatic SCI patient from the time of injury through the stay in the intensive care unit. We discuss initial triage, immobilization, and transportation of the patient by emergency medical services personnel to a definitive treatment facility. Upon arrival at the emergency department, we review initial trauma protocols and the evidence-based recommendations for radiographic evaluation of the patient's vertebral column. Finally, we outline closed cervical spine reduction and various aggressive medical therapies aimed at improving neurologic outcome.
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Affiliation(s)
- C D Shank
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - B C Walters
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - M N Hadley
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA.
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35
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Lin JL, Samuel S, Gray R, Ruff S, Vasili C, Cree A, Hartin N. Occult subaxial cervical disco-ligamentous injuries in computer tomography negative trauma patients. 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 2016; 26:1277-1283. [PMID: 28028650 DOI: 10.1007/s00586-016-4925-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 11/21/2016] [Accepted: 12/16/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Due to lack of cervical clearance consensus in literature and the devastating consequences of missed cervical injuries, Magnetic resonance imaging (MRI) of the neurologically intact symptomatic patient with negative CT scan is frequently done to rule out disco-ligamentous injuries. This study retrospectively evaluates occult disco-ligamentous injuries detected by MRI in patients with no abnormalities detected by modern multi-detector CT scanning and postulates a new theory of ligamentous stability of cervical spine. METHODS Cervical spine injury patients treated at a spinal trauma referral centre from 2010 to 2013 were retrospectively identified. Available clinical records and radiographic imaging were reviewed to find neurologically intact symptomatic patients with no identifiable acute cervical spine injury on CT scan but MRI evidence of isolated subaxial disco-ligamentous injuries. Patient demographics, injury profile, and treatment details were extracted. Subaxial Cervical Spine Injury Classification (SLIC) and Denis three-column spinal stability theory were adopted to assess stability of injuries. RESULT 316/566 cervical spinal admissions had CT and MRI scans. 11 (3.5%) CT negative patients were found to have occult discoligamentous injuries on MRI. The average age (51.1 years) was not significantly different to all cervical trauma admissions (p = 0.09). Eight had flexion type and three had extension type injuries. The most common mechanisms were sports and fall on flat surface. The average SLIC score was 3.1. Four patients were classified as having unstable or potentially unstable injuries (two patients each) and three of these patients were surgically managed. Subtle CT changes to indicate discoligamentous injury could be retrospectively identified in all four of these patients. CONCLUSION CT scans alone may be inadequate for clearing occult disco-ligamentous injuries of the subaxial cervical spine in trauma. Denis three-column stability theory may be beneficial in determining stability and guiding treatment along with the SLIC system for occult discoligamentous injuries of the subaxial cervical spine.
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Affiliation(s)
- Jiun-Lih Lin
- Department of Orthopaedic and Trauma Surgery, Royal North Shore Hospital, Sydney, Australia.
- Sydney Medical School, University of Sydney, Sydney, Australia.
| | - Sumant Samuel
- Department of Orthopaedic and Trauma Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Randolph Gray
- Department of Orthopaedic and Trauma Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Stephen Ruff
- Department of Orthopaedic and Trauma Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Con Vasili
- Department of Orthopaedic and Trauma Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Andrew Cree
- Department of Orthopaedic and Trauma Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Nathan Hartin
- Department of Orthopaedic and Trauma Surgery, Royal North Shore Hospital, Sydney, Australia
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36
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Kasliwal MK, Fontes RB, Traynelis VC. Occipitocervical dissociation-incidence, evaluation, and treatment. Curr Rev Musculoskelet Med 2016; 9:247-54. [PMID: 27255101 PMCID: PMC4958379 DOI: 10.1007/s12178-016-9347-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Traumatic occipitocervical dissociation (OCD) results from ligamentous injury to the craniocervical junction and is associated with a high rate of mortality and significant neurologic morbidity. The diagnosis is frequently missed on initial lateral cervical spinal radiographs mainly due to inadequate visualization of radiological landmarks and low degree of suspicion. Widespread availability of multidetector computed tomography (MDCT) of the spine and development of better diagnostic radiological criteria has allowed timely diagnosis and good clinical outcome following posterior occipitocervical fusion and instrumentation for a pathology that was once considered uniformly fatal. The present paper reviews the clinical features, diagnosis, and management of OCD in light of most recent literature.
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Affiliation(s)
- Manish K Kasliwal
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St., Chicago, IL, 60612, USA
| | - Ricardo B Fontes
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St., Chicago, IL, 60612, USA
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St., Chicago, IL, 60612, USA.
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37
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Malhotra A, Wu X, Kalra VB, Nardini HKG, Liu R, Abbed KM, Forman HP. Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis. Eur Radiol 2016; 27:1148-1160. [PMID: 27334017 DOI: 10.1007/s00330-016-4426-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 04/20/2016] [Accepted: 05/20/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To quantify the rate of unstable injuries detected by MRI missed on CT in blunt cervical spine (CS) trauma patients and assess the utility of MRI in CS clearance. METHODS We undertook a systematic review of worldwide evidence across five major medical databases and performed a meta-analysis. Studies were included if they reported the number of unstable injuries or gave enough details for inference. Variables assessed included severity, CT/MRI specifications, imaging timing, and outcome/follow-up. Pooled incidences of unstable injury on follow-up weighted by inverse-of-variance among all included and obtunded or alert patients were reported. RESULTS Of 428 unique citations, 23 proved eligible, with 5,286 patients found, and 16 unstable injuries reported in five studies. The overall pooled incidence is 0.0029 %. Among studies reporting only obtunded patients, the pooled incidence is 0.017 %. In alert patients, the incidence is 0.011 %. All reported positive findings were critically reviewed, and only 11 could be considered truly unstable. CONCLUSIONS There is significant heterogeneity in the literature regarding the use of imaging after a negative CT. The finding rate on MRI for unstable injury is extremely low in obtunded and alert patients. Although MRI is frequently performed, its utility and cost-effectiveness needs further study. KEY POINTS • There were 16 unstable injuries on follow-up MRI among 5286 patients. • The positive finding rate among obtunded patients was 0.12 %. • The positive finding rate among alert, awake patients was 0.72 %. • MRI has a high false-positive rate; its utility mandates further studies. • The use and role of "confirmatory" tests shows wide variations.
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Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA.
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA
| | - Vivek B Kalra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA
| | - Holly K Grossetta Nardini
- Research and Education Librarian, Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Renu Liu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA
| | - Khalid M Abbed
- Minimally Invasive Spine Surgery & Spine Tumor Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, 333 Cedar St, Box 208042, New Haven, CT, 06520-8042, USA
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Abstract
Traumatic spinal cord injuries (SCIs) affect 1.3 million North Americans, producing devastating physical, social, and vocational impairment. Pathophysiologically, the initial mechanical trauma is followed by a significant secondary injury which includes local ischemia, pro-apoptotic signaling, release of cytotoxic factors, and inflammatory cell infiltration. Expedient delivery of medical and surgical care during this critical period can improve long-term functional outcomes, engendering the concept of "Time is Spine". We emphasize the importance of expeditious care while outlining the initial clinical and radiographic assessment of patients. Key evidence-based early interventions (surgical decompression, blood pressure augmentation, and methylprednisolone) are also reviewed, including findings of the landmark Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). We then describe other neuroprotective approaches on the edge of translation such as the sodium-channel blocker riluzole, the anti-inflammatory minocycline, and therapeutic hypothermia. We also review promising neuroregenerative therapies that are likely to influence management practices over the next decade including chondroitinase, Rho-ROCK pathway inhibition, and bioengineered strategies. The importance of emerging neural stem cell therapies to remyelinate denuded axons and regenerate neural circuits is also discussed. Finally, we outline future directions for research and patient care.
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Affiliation(s)
- Christopher S Ahuja
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Allan R Martin
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Michael Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; McEwen Centre for Regenerative Medicine, UHN, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Spine Program, University of Toronto, Toronto, Ontario, Canada; McLaughlin Center in Molecular Medicine, University of Toronto, Toronto, Ontario, Canada
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Ducis K, Florman JE, Rughani AI. Appraisal of the Quality of Neurosurgery Clinical Practice Guidelines. World Neurosurg 2016; 90:322-339. [PMID: 26947727 DOI: 10.1016/j.wneu.2016.02.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The rate of neurosurgery guidelines publications was compared over time with all other specialties. Neurosurgical guidelines and quality of supporting evidence were then analyzed and compared by subspecialty. METHODS The authors first performed a PubMed search for "Neurosurgery" and "Guidelines." This was then compared against searches performed for each specialty of the American Board of Medical Specialties. The second analysis was an inventory of all neurosurgery guidelines published by the Agency for Healthcare Research and Quality Guidelines clearinghouse. All Class I evidence and Level 1 recommendations were compared for different subspecialty topics. RESULTS When examined from 1970-2010, the rate of increase in publication of neurosurgery guidelines was about one third of all specialties combined (P < 0.0001). However, when only looking at the past 5 years the publication rate of neurosurgery guidelines has converged upon that for all specialties. The second analysis identified 49 published guidelines for assessment. There were 2733 studies cited as supporting evidence, with only 243 of these papers considered the highest class of evidence (8.9%). These papers were used to generate 697 recommendations, of which 170 (24.4%) were considered "Level 1" recommendations. CONCLUSION Although initially lagging, the publication of neurosurgical guidelines has recently increased at a rate comparable with that of other specialties. However, the quality of the evidence cited consists of a relatively low number of high-quality studies from which guidelines are created. Wider implications of this must be considered when defining and measuring quality of clinical performance in neurosurgery.
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Affiliation(s)
- Katrina Ducis
- Division of Neurosurgery, Department of Surgery, University of Vermont, Burlington, Vermont, USA.
| | - Jeffrey E Florman
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Anand I Rughani
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA; Center for Excellence in Neuroscience, University of New England, Biddeford, Maine, USA
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Roy AK, Miller BA, Holland CM, Fountain AJ, Pradilla G, Ahmad FU. Magnetic resonance imaging of traumatic injury to the craniovertebral junction: a case-based review. Neurosurg Focus 2015; 38:E3. [PMID: 25828497 DOI: 10.3171/2015.1.focus14785] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECT The craniovertebral junction (CVJ) is unique in the spinal column regarding the degree of multiplanar mobility allowed by its bony articulations. A network of ligamentous attachments provides stability to this junction. Although ligamentous injury can be inferred on CT scans through the utilization of craniometric measurements, the disruption of these ligaments can only be visualized directly with MRI. Here, the authors review the current literature on MRI evaluation of the CVJ following trauma and present several illustrative cases to highlight the utility and limitations of craniometric measures in the context of ligamentous injury at the CVJ. METHODS A retrospective case review was conducted to identify patients with cervical spine trauma who underwent cervical MRI and subsequently required occipitocervical or atlantoaxial fusion. Craniometric measurements were performed on the CT images in these cases. An extensive PubMed/MEDLINE literature search was conducted to identify publications regarding the use of MRI in the evaluation of patients with CVJ trauma. RESULTS The authors identified 8 cases in which cervical MRI was performed prior to operative stabilization of the CVJ. Craniometric measures did not reliably rule out ligamentous injury, and there was significant heterogeneity in the reliability of different craniometric measurements. A review of the literature revealed several case series and descriptive studies addressing MRI in CVJ trauma. Three papers reported the inadequacy of the historical Traynelis system for identifying atlantooccipital dislocation and presented 3 alternative classification schemes with emphasis on MRI findings. CONCLUSIONS Recognition of ligamentous instability at the CVJ is critical in directing clinical decision making regarding surgical stabilization. Craniometric measures appear unreliable, and CT alone is unable to provide direct visualization of ligamentous injury. Therefore, while the decision to obtain MR images in CVJ trauma is largely based on clinical judgment with craniometric measures used as an adjunct, a high degree of suspicion is warranted in the care of these patients as a missed ligamentous injury can have devastating consequences.
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Lukins TR, Ferch R, Balogh ZJ, Hansen MA. Cervical spine immobilization following blunt trauma: a systematic review of recent literature and proposed treatment algorithm. ANZ J Surg 2015; 85:917-22. [PMID: 26177678 DOI: 10.1111/ans.13221] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Management of the cervical spine following blunt trauma is commonplace. In 2013, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) published practice guidelines drawn from evidence dating to 2011. Since then, further publications have emerged that are reviewed, and a simple management algorithm produced to assist practitioners in Australian trauma centres. These publications attempt to shed light on two controversial scenarios, those being the management of symptomatic patients with negative computed tomography (CT) and management of the obtunded patient. METHODS The search strategy mirrored that of the AANS/CNS guidelines. A search of the National Library of Medicine (PubMed) database for manuscripts published between January 2011 and October 2014 was conducted. One reviewer extracted data from studies assessing the performance of various imaging modalities in identifying traumatic cervical spine injuries. In clinical scenarios where little evidence has emerged since the AANS/CNS guidelines, key manuscripts published prior to 2011 were identified from bibliographies. RESULTS Awake, asymptomatic patients may be 'cleared' without further imaging. Awake, symptomatic patients without pathology on CT and without neurological deficit can safely be 'cleared' without magnetic resonance imaging. There is no longer a role for flexion-extension films. In the obtunded patient, findings remain conflicting. CONCLUSION Several of these findings represent a departure from previous practices, including clearance of patients with non-neurological symptoms on the basis of CT and the exclusion of flexion-extension film in detecting injury. Management of the obtunded patient remains controversial.
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Affiliation(s)
- Timothy R Lukins
- Department of Neurosurgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Richard Ferch
- Department of Neurosurgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia
| | - Mitchell A Hansen
- Department of Neurosurgery, John Hunter Hospital, Newcastle, New South Wales, Australia
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Martin AR, Aleksanderek I, Fehlings MG. Diagnosis and Acute Management of Spinal Cord Injury: Current Best Practices and Emerging Therapies. CURRENT TRAUMA REPORTS 2015. [DOI: 10.1007/s40719-015-0020-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Ropper AE, Neal MT, Theodore N. Acute management of traumatic cervical spinal cord injury. Pract Neurol 2015; 15:266-72. [PMID: 25986457 DOI: 10.1136/practneurol-2015-001094] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2015] [Indexed: 11/03/2022]
Abstract
Patients with acute cervical spinal cord injury present complex clinical challenges. These injuries may result in motor and sensory deficits and also in cardiovascular and respiratory perturbations. Increased attention to critical care support has led to improved survival and recovery in many patients. The methods and technology used to diagnose and classify these injuries as well as medical and surgical treatments have evolved significantly in recent decades. We review important aspects of the diagnosis and acute care of patients with traumatic cervical spinal cord injuries, emphasising the recent evidence.
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Affiliation(s)
- Alexander E Ropper
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Matthew T Neal
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Emohare O, Dittmer A, Morgan RA, Switzer JA, Polly DW. Osteoporosis in acute fractures of the cervical spine: the role of opportunistic CT screening. J Neurosurg Spine 2015; 23:1-7. [PMID: 25860516 DOI: 10.3171/2014.10.spine14233] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Recently published data make it possible to generate estimates of bone mineral density (BMD) by using CT attenuation; this innovation can save time and reduce costs. Although advanced age is associated with reduced BMD, especially in patients with a fracture of C-2, relatively few patients ever undergo formal dual x-ray absorptiometry studies. To the authors' knowledge, this is the first study to assess the utility of this technique in elucidating BMD in patients with an acute fracture of the cervical spine. METHODS Patients who presented to a Level I trauma center with an acute fracture of the cervical spine and underwent abdominal (or L-1) CT scanning either at admission or in the 6 months before or after the injury were evaluated. Using a picture-archiving and communication system, the authors generated regions of interest of similar size in the body of L-1 (excluding the cortex) and computed mean values for CT attenuation. The values derived were compared with threshold values, which differentiate between osteoporotic and nonosteoporotic states; age-stratified groups were also compared. RESULTS Of the 91 patients whose data were reviewed, 51 were < 65 years old (mean 43.2 years) and 40 were ≥ 65 years old (mean 80.9 years). The overall mean CT attenuation values (in Hounsfield units [HU]), stratified according to age, were 193.85 HU for the younger cohort and 117.39 HU for the older cohort; the result of a comparison between these two values was significant (p < 0.001). CONCLUSIONS Using opportunistic CT scanning, this study demonstrates the relative frequency of osteoporosis in acute fractures of the cervical spine. It also objectively correlates overall BMD with the known higher frequency of C-2 fractures in older patients. This technique harnesses the presence of opportunistic CT scans of the abdomen, which potentially reduces the need for the extra time and cost that may be associated with dual x-ray absorptiometry scanning.
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Affiliation(s)
| | - Alison Dittmer
- University of Minnesota Medical School, Minneapolis; and
| | - Robert A Morgan
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Julie A Switzer
- Orthopaedic Surgery, Regions Hospital, St. Paul;,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - David W Polly
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Cervical spine clearance protocols in Level I, II, and III trauma centers in California. Spine J 2015; 15:398-404. [PMID: 25546512 DOI: 10.1016/j.spinee.2014.12.142] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 12/02/2014] [Accepted: 12/19/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cervical spine clearance protocols were developed to standardize the clearance of the cervical spine after blunt trauma and prevent secondary neurologic injuries. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in California is unknown. PURPOSE To evaluate the cervical spine clearance protocols in all trauma centers of California. STUDY DESIGN An observational cross-sectional study. PATIENT SAMPLE Included from Level I, II, III trauma centers in California. OUTCOME MEASURES The self-reported outcomes of each trauma center's cervical spine clearance protocols were assessed. METHODS Level I (n=15), II (n=30), and III (n=11) trauma centers in California were contacted. Each available protocol was reviewed for four scenarios: clearing the asymptomatic patient, the initial imaging modality used in patients not amenable to clinical clearance, and the management strategies for patients with persistent neck pain with a negative computed tomography (CT) scan and those who are obtunded. Results were compared with the 2009 Eastern Association for the Surgery of Trauma (EAST) cervical spine clearance guidelines. RESULTS The response rate was 96%. Sixty-three percent of California's trauma centers (Level I, 93%; Level II, 60%; Level III, 27%) had written cervical spine clearance protocols. For asymptomatic patients, 83% of Level I and 61% of Level II centers used National Emergency X-Radiography Utilization Study criteria with/without painless range of motion. For those requiring imaging, 67% of Level I and 56% of Level II centers stated a CT scan should be the first line of imaging. For obtunded patients and patients with persistent neck pain and a negative CT scan, more than 90% of Level I and more than 70% of Level II trauma centers incorporated the 2009 EAST recommendations. No institution recommended passive flexion-extension radiographs for the obtunded patient. CONCLUSIONS Written cervical spine clearance protocols exist in 63% of California's trauma centers and only 51% of the centers have protocols that follow current evidence-based guidelines. Standardization and utilization of these protocols should be encouraged to prevent missed injuries and secondary neurologic injuries.
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Abstract
OPINION STATEMENT Spinal cord injury (SCI) causes significant morbidity and mortality. Clinical management in the acute setting needs to occur in the intensive care unit in order to identify, prevent, and treat secondary insults from local ischemia, hypotension, hypoxia, and inflammation. Maintenance of adequate perfusion and oxygenation is quintessential and a mean arterial pressure >85-90 mm Hg should be kept for at least 1 week. A cervical collar and full spinal precautions (log-roll, flat, holding C-spine) should be maintained until the spinal column has been fully evaluated by a spine surgeon. In patients with SCI, there is a high incidence of other bodily injuries, and there should be a low threshold to assess for visceral, pelvic, and long bone injuries. Computed tomography of the spine is superior to plain films, as the former rarely misses fractures, though caution needs to be exerted as occipitocervical dislocation can still be missed. To reliably assess the spinal neural elements, soft tissues, and ligamentous structures, magnetic resonance imaging is indicated and should be obtained within 48-72 h from the time of injury. All patients should be graded daily using the American Spinal Injury Association classification, with the first prognostic score at 72 h postinjury. Patients with high cervical cord (C4 or higher) injury should be intubated immediately, and those with lower cord injuries should be evaluated on a case-by-case basis. However, in the acute setting, respiratory mechanics will be disrupted with any spinal cord lesion above T11. Steroids have become extremely controversial, and the professional societies for neurosurgery in the United States have given a level 1 statement against their use in all patients. We, therefore, do not advocate for them at this time. With every SCI, a spine surgeon must be consulted to discuss operative vs nonoperative management strategies. Indications for surgery include a partial or progressive neurologic deficit, instability of the spine not allowing for mobilization, correction of a deformity, and prevention of potential neurologic compromise. Measures to prevent pulmonary emboli from deep venous thromboembolisms are necessary: IVC filters are recommended in bedbound patients and low-molecular weight heparins are superior to unfractionated heparin. Robust prevention of pressure ulcers as well as nutritional support should be a mainstay of treatment. Lastly, it is important to note that neurologic recovery is a several-year process. The most recovery occurs in the first year following injury, and therefore aggressive rehabilitation is crucial.
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Abstract
STUDY DESIGN Observational, cross-sectional. OBJECTIVE To evaluate cervical spine clearance protocols in level 1 trauma centers in the United States. SUMMARY OF BACKGROUND DATA Cervical spine clearance protocols were developed to prevent missed injuries that could result in neurological deficits. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in the United States is unknown. METHODS Level 1 trauma (n = 191) centers in the United States were contacted. Each available protocol was reviewed for 4 scenarios: clearing the asymptomatic patient, the imaging used in patients not amenable to clinical clearance, the management strategies for patients with persistent neck pain with a negative computed tomographic (CT) scan, and those who are obtunded. RESULTS The response rate was 87%. Cervical spine clearance protocols existed in 57% of the institutions. National Emergency X-Radiography Utilization Study criteria to clear asymptomatic patients were recommended in 89% of protocols. Sixty percent of protocols used CT scans as the first line of imaging. In patients with persistent neck pain with negative CT scan flexion-extension plain radiographs were the most common (30%) next step for clearance. In patients who are obtunded, a CT scan followed by a magnetic resonance imaging was the most common method (31%) of clearance. Eight percent of the protocols recommended dynamic flexion-extension views in patients who are obtunded, which are contraindicated. CONCLUSION Written cervical spine clearance protocols exist in 57% of level 1 trauma centers in the United States. These protocols are highly variable and standardization and utilization of these protocols should be encouraged in all trauma centers to prevent missed injuries and neurological catastrophes. LEVEL OF EVIDENCE 4.
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Comparison of CT and MRI findings for cervical spine clearance in obtunded patients without high impact trauma. Clin Neurol Neurosurg 2014; 120:23-6. [PMID: 24731570 DOI: 10.1016/j.clineuro.2014.02.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 10/12/2013] [Accepted: 02/17/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Cervical spinal injuries occur in 2.0-6.6% of patients after blunt trauma and can have devastating neurological sequelae if left unrecognized. Although there is high quality evidence addressing cervical clearance in asymptomatic and symptomatic awake patients, cervical spine clearance in patients with altered level of alertness (i.e., obtunded patients with Glasgow coma scale (GCS) of 14 or less) following blunt trauma has been a matter of great controversy. Furthermore, there are no data on cervical spine clearance in obtunded patients without high impact trauma and these patients are often treated based on evidence from similar patients with high impact trauma. This retrospective study was conducted on this specific subgroup of patients who were admitted to a neurointensive care unit (NICU) with primary diagnoses of intracranial hemorrhage with history of minor trauma; the objective being to evaluate and compare cervical spinal computed tomography (CT) and magnetic resonance imaging (MRI) findings in this particular group of patients. METHODS Patients with GCS of 14 or less admitted to neruointensive care unit (NICU) at RUSH University Medical Center from 2008 to 2010 with diagnoses of intracranial hemorrhage (surgical or non-surgical) who had reported or presumed fall (i.e., "found down") were queried from the computer data registry. A group of these patients had cervical spine CT and subsequently MRI for clearing the cervical spine and removal of the cervical collar. Medical records of these patients were reviewed for demographics, GCS score and injury specific data and presence or absence of cervical spine injury. RESULTS Eighty-three patients were identified from the computer database. Twenty-eight of these patients had positive findings on both CT and MRI (33.73% - Group I); four patients had a negative CT but had positive findings on follow-up MRI (4.82% - Group II); fifty-one patients had both negative CT and MRI (61.44% - Group III). All patients in Group I required either surgical stabilization or continuation of rigid cervical orthosis. All four patients in Group II had intramedullary T2 hyper intensity consistent with possible spinal cord injury on MRI, but did not have any signs of fracture or ligamentous injury to suggest instability. They eventually underwent surgical decompression of the spinal cord during the same hospital stay. Cervical collars were safely removed in all patients in Group III. In our retrospective study, CT had a sensitivity of 0.875 [0.719-0.950, 95% CI] and a specificity of 1.000 [0.930-1.000, 95% CI] in detecting all cervical spine injuries compared to MRI. However, all patients with missed injuries had intramedullary T2 hyper intensity consistent with possible spinal cord injury on MRI and were not unstable precluding cervical spine clearance. If only unstable injuries are considered, CT had a sensitivity of 1.00 [0.879-1.000, 95% CI] and a specificity is 1.000 [0.935-1.000, 95% CI] compared to MRI in this particular group of patients. CONCLUSION CT is highly sensitive in detecting unstable injuries in obtunded patients with GCS of 14 or less in the absence of high impact trauma. In the absence of high impact trauma, neurosurgeons should be comfortable to discontinue the cervical collar after a negative, high-quality CT in this patient population. In the presence of focal neurological deficits unexplained by associated intracranial injury, an MRI may help diagnose intrinsic spinal cord injuries which necessarily may not be unstable in the presence of a negative CT and does not precludes clearance of cervical spine.
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Raniga SB, Menon V, Al Muzahmi KS, Butt S. MDCT of acute subaxial cervical spine trauma: a mechanism-based approach. Insights Imaging 2014; 5:321-38. [PMID: 24554380 PMCID: PMC4035495 DOI: 10.1007/s13244-014-0311-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/22/2013] [Accepted: 01/13/2014] [Indexed: 11/27/2022] Open
Abstract
Injuries to the spinal column are common and road traffic accidents are the commonest cause. Subaxial cervical spine (C3–C7) trauma encompasses a wide spectrum of osseous and ligamentous injuries, in addition to being frequently associated with neurological injury. Multidetector computed tomography (MDCT) is routinely performed to evaluate acute cervical spine trauma, very often as first-line imaging. MDCT provides an insight into the injury morphology, which in turn reflects the mechanics of injury. This article will review the fundamental biomechanical forces underlying the common subaxial spine injuries and resultant injury patterns or “fingerprints” on MDCT. This systematic and focused analysis enables a more accurate and rapid interpretation of cervical spine CT examinations. Mechanical considerations are important in most clinical and surgical decisions to adequately realign the spine, to prevent neurological deterioration and to facilitate appropriate stabilisation. This review will emphasise the variables on CT that affect the surgical management, as well as imaging “pearls” in differentiating “look-alike” lesions with different surgical implications. It will also enable the radiologist in writing clinically relevant CT reports of cervical spine trauma. Teaching Points • Vertebral bodies and disc bear the axial compression forces, while the ligaments bear the distraction forces. • Compressive forces result in fracture and distractive forces result in ligamentous disruption. • Bilateral facet dislocation is the most severe injury of the flexion-distraction spectrum. • Biomechanics-based CT reading will help to rapidly and accurately identify the entire spectrum of injury. • This approach also helps to differentiate look-alike injuries with different clinical implications.
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Affiliation(s)
- Sameer B Raniga
- Division of Radiology, Khoula Hospital, PO BOX 794, Muscat, 117, Oman,
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Clinical applicability of magnetic resonance imaging in acute spinal cord trauma. 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 2013; 23:1457-63. [PMID: 24091790 DOI: 10.1007/s00586-013-3047-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 09/25/2013] [Accepted: 09/25/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To assess the clinical application of magnetic resonance imaging (MRI) in patients with acute spinal cord trauma (SCT) according to the type, extension, and severity of injury and the clinical-radiological correlation. METHODS Diagnostic imaging [computed tomography (CT) and MRI] tests of 98 patients with acute SCT were analyzed to assess their clinical diagnostic value. The following radiological findings of SCT were investigated: vertebral compression fractures, bursts and dislocations, posterior element fractures, C1 and C2 lesions, vertebral listhesis, bone swelling, spinal canal compression, disk herniation, extradural hematoma, spinal cord contusions, spinal cord swelling, and posterior ligamentous complex (PLC) injuries. RESULTS The radiological findings were better visualized using MRI, except for the posterior elements (p = 0.001), which were better identified with CT. A total of 271 lesions were diagnosed as follows: 217 using MRI, 154 using CT, and 100 (36.9 %) using both MRI and CT. MRI detected 117 more lesions than CT. CONCLUSION MRI was significantly superior to CT in the diagnosis of bone swelling, PLC injury, disk herniation, spinal canal compression, spinal cord contusion and swelling present in SCT. MRI detected a larger number of lesions than CT and is highly useful for the diagnosis of soft tissue and intrathecal injuries.
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