Clinical complications in patients with severe cervical spinal trauma: a ten-year prospective study

The effect of ATLS/PHTLS spinal motion restriction protocol on the incidence of spinal cord injury, a nationwide database study

PURPOSE

To study trends in incidence and outcome of patients with traumatic spinal cord injury (TSCI) in the Netherlands before, during and after implementation of the Advanced Trauma Life Support (ATLS®) and Pre-Hospital Trauma Life Support (PHTLS®)- Spinal Motion Restriction(SMR) protocol.

METHODS

In an observational database we studied national hospital admission and emergency department databases to analyse incidence rates and outcome of traumatic spinal cord injury and spinal fractures in the emergency department and in admittances in The Netherlands between 1986 and 2021.

RESULTS

A significant increase of 39% in TSCI in admitted patients with spinal fractures over the past 35 years (p < 0.001). This increase was especially prevalent in cervical spinal fractures (132%), while thoracic and lumbosacral spinal fractures showed a decrease in accompanied TSCI (64% and 88% respectively). The overall increase in spinal fractures was not significant. The duration of hospital admission decreased for spinal fractures without TSCI and with TSCI (66% and 56% respectively).

CONCLUSION

Since implementation of the SMR-protocol was aiming to limit TSCI in patients who suffered a spinal fracture, the increase in TSCI is an unexpected finding. Exact explanation for this increase is unclear and the contribution of the SMR-protocol is not fully understood due to confounders in the used datasets. Either way, the scientific evidence supporting this costly time- and labor-intensive SMR-protocol remains debated, along with evidence contradicting it. Therefore it stresses the need for clear, evidencebased reasoning for spinal immobilization according to ATLS, as this is currently lacking.

An Epidemiological Overview of Spinal Trauma in the Kingdom of Saudi Arabia

INTRODUCTION

The World Report on Road Traffic Injury Prevention indicates that by 2020, road traffic injuries will be a major killer, accounting for half a million deaths and 15 million disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) has one of the highest rates of spinal cord injuries in the world, with 62 people injured per 1 million, and the injuries are mostly due to traffic accidents.

METHODS

All polytrauma patients associated with spinal injuries admitted to Prince Mohammed bin Abdul Aziz Hospital (PMAH), Riyadh, from January 2017 to June 2018, were included in this study. Patients with old spinal injuries, any previous spinal surgery, spine infection, or concomitant diagnosed malignancies or osteoporotic collapse with or without falls were excluded. All patients underwent whole-spine computed tomography scan and, in selective cases, magnetic resonance imaging of the spine.

RESULTS

Of the 230 patients, 90.0% were male, and 60% were in the second and third decades. Motor vehicle accidents were responsible for 83% of the cases, of which 50% of the victims were the drivers, and 80% were passengers with no seatbelt on. Nearly 50% of the spinal injuries were associated with injuries in the other body parts. Cervical spine injury accounted for 44% of the cases, followed by the lumbar spine injury. Twenty five percent of the patients presented with fixed neurologic deficit in the form of quadriplegia or paraplegia (ASIA-A). The mortality rate was 1.3%.

CONCLUSIONS

This study revealed that motor vehicle accidents are a major cause of spinal injuries in the KSA. One-fourth of the spinal Injuries are associated with complete spinal cord injuries. Therefore, in order to prevent lifelong disability in the young population, a nationwide program should be initiated to prevent road traffic accidents.

Management of Pharyngeal Fistulas After Anterior Cervical Spine Surgery: A Treatment Algorithm for Severe Complications

STUDY DESIGN

This study is a retrospective database query to identify all anterior spinal approaches.

OBJECTIVES

The objectives were to assess all patients with pharyngocutaneous fistulas (PCFs) after anterior cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Patients with the diagnosis of PCFs were treated at the University of Heidelberg Spine Medical Center, Spinal Cord Injury Unit and Department of Otolaryngology (Germany), between 2005 and 2011.

METHODS

We conducted a retrospective study on 5 patients with PCF after anterior cervical spine surgery between 2005 and 2011 and analyzed their therapy management and outcome on the basis of the radiologic data and patient charts.

RESULTS

Upon presentation, 4 patients were paraplegic. Two patients had PCF arising from 1 piriform sinus, 2 patients had PCF arising from the posterior pharyngeal wall and piriform sinus combined, and 1 patient had PCF arising only from the posterior pharyngeal wall. Two patients previously underwent unsuccessful surgical repair elsewhere and 1 patient underwent a prior radiation therapy. In 3 patients, speech and swallowing could be completely restored. Two patients died, both of whom were paraplegic. The patients were needed to undergo an average of 2 or 3 procedures for complete functional recovery of primary closure with various vascularized regional flaps and refining laser procedures supplemented with the negative pressure wound therapy wherever needed.

CONCLUSIONS

On the basis of our experience, we are able to provide a treatment algorithm that indicates that chronic, as opposed to acute, fistulas require a primary surgical closure combined with a vascularized flap that should be accompanied by the immediate application of a negative pressure wound therapy. We also conclude that particularly in paraplegic patients suffering from this complication the risk for a fatal outcome is substantial.

Characteristics and clinical aspects of patients with spinal cord injury undergoing surgery

Objective

To identify the characteristics of patients with spinal cord injury (SCI) undergoing surgery.

Methods

Previously, 321 patients with SCI were selected. Clinical and socio-demographic variables were collected.

Results

A total of 211 patients were submitted to surgery. Fall and injuries in the upper cervical and lumbosacral regions were associated with conservative treatment. Patients with lesions in the lower cervical spine, worse neurological status, and unstable injuries were associated with surgery. Individuals undergoing surgery were associated with complications after treatment. The authors assessed whether age influenced the characteristics of patients submitted to surgery. Subjects with <60 years of age were associated with motorcycle accidents and the morphologies of injury were fracture-dislocation. Elderly individuals were associated to fall, SCI in the lower cervical spine and the morphology of injury was listhesis. Subsequently, the authors analyzed the gender characteristics in these patients. Women who suffered car accidents were associated to surgery. Women were associated with paraparesis and the morphologic diagnosis was fracture-explosion, especially in the thoracolumbar transition and lumbosacral regions. Men who presented traumatic brain injury and thoracic trauma were related to surgery. These individuals had a worse neurological status and were associated to complications. Men and the cervical region were most affected, thereby, these subjects were analyzed separately (n = 92). The presence of complications increased the length of hospital stay. The simultaneous presence of morphological diagnosis, worst neurological status, tetraplegia, sensory, and motor alterations were associated with complications. Pneumonia and chest trauma were associated with mortality.

Conclusion

These factors enable investments in prevention, rehabilitation, and treatment.

Complications in the Management of Patients with Spine Trauma

More than 50% of patients diagnosed with acute, traumatic spinal cord injury will experience at least 1 complication during their hospitalization. Age, severity of neurological injury, concurrent traumatic brain injury, comorbid illness, and mechanism of injury are all associated with increasing risk of complication. More than 75% of complications will occur within 2 weeks of injury. The complications associated with SCI carry a significant risk of morbidity and mortality; their early identification and management is critical in the care of the SCI patient.

Pressure ulcers in people with spinal cord injury in developing nations

STUDY DESIGN

Literature review.

OBJECTIVES

To explore the prevalence or incidence, risk factors, and costs of pressure ulcers among individuals with spinal cord injury (SCI), specifically in the context of the developing world. To highlight important targets for intervention and research for pressure ulcer management the world over.

SETTING

World Bank 'low-income' and 'middle-income' countries with a gross national income per capita <$12 746.

METHODS

PubMed search.

RESULTS

SCI-associated pressure ulcers are very prevalent in developing nations; however, reported prevalence and incidence numbers are highly variable. Risk factors for pressure ulcers are similar in developed and developing countries however many of the risk factors are more prevalent in developing nations.

CONCLUSION

SCI-associated pressure ulcers are common but can be prevented in the developing world. Key targets for interventions include acute care, nurse-to-patient ratios, support surfaces and education.

Predictors of clinical complications in patients with spinomedullary injury

Objective: To analyze individuals with spinal cord injury who developed secondary clinical complications, and the variables that can influence the prognosis. Methods: A prospective study of 321 patients with spinal cord injury. The variables were collected: age, sex, cause of the accident, anatomical distribution, neurological status, associated injuries, in-hospital complications, and mortality only in patients who developed complications. Results: A total of 72 patients were analyzed (85% male) with a mean age of 44.72±19.19 years. The individuals with spinal cord injury who developed clinical complications were mostly male, over 50 years of age, and the main cause was accidental falls. These patients had longer hospitalization times and a higher risk of progressing to death. Pneumonia was the main clinical complication. With regard to the variables that can influence the prognosis of these patients, it was observed that spinal cord injury to the cervical segment with syndromic quadriplegia, and neurological status ASIA-A, have a higher risk of developing pneumonia, the most common complication, as well as increased mortality. Conclusion: Clinical complications secondary to spinal cord injury are influenced by demographic factors, as well as characteristics of the injury contributing to an increase in mortality.