Triage tools for detecting cervical spine injury in paediatric trauma patients

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.

Incidence, prevalence, and causes of spinal injuries in China, 1990-2019: Findings from the Global Burden of Disease Study 2019

BACKGROUND

Spinal injuries are an urgent public health priority; nevertheless, no China-wide studies of these injuries exist. This study measured the incidence, prevalence, causes, regional distribution, and annual trends of spinal injuries in China from 1990 to 2019.

METHODS

We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 to estimate the incidence and prevalence of spinal injuries in China. The data of 33 provincial-level administrative regions (excluding Taiwan, China) provided by the National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention (CDC) were use to systematically analyze the provincial etiology, geographical distribution, and annual trends of spinal injuries. The Bayesian meta-regression tool DisMod-MR 2.1 was used to ensure the consistency among incidence, prevalence, and mortality rates in each case.

RESULTS

From 1990 to 2019, the number of living patients with spinal injuries in China increased by 138.32%, from 2.14 million to 5.10 million, while the corresponding age-standardized prevalence increased from 0.20% (95% uncertainty interval [UI]: 0.18-0.21%) to 0.27% (95% UI: 0.26-0.29%). The incidence of spinal injuries in China increased by 89.91% (95% UI: 72.39-107.66%), and the prevalence increased by 98.20% (95% UI: 89.56-106.82%), both the most significant increases among the G20 countries; 71.00% of the increase could be explained by age-specific prevalence. In 2019, the incidence was 16.47 (95% UI: 12.08-22.00, per 100,000 population), and the prevalence was 358.30 (95% UI: 333.96-386.62, per 100,000 population). Based on the data of 33 provincial-level administrative regions provided by CDC, age-standardized incidence and prevalence were both highest in developed provinces in Eastern China. The primary causes were falls and road injuries; however, the prevalence and specific causes differed across provinces.

CONCLUSIONS

In China, the overall disease burden of spinal injuries increased significantly during the past three decades but varied considerably according to geographical location. The primary causes were falls and road injuries; however, the prevalence and specific causes differed across provinces.

Machine Learning and Deep Learning in Spinal Injury: A Narrative Review of Algorithms in Diagnosis and Prognosis

Spinal injuries, including cervical and thoracolumbar fractures, continue to be a major public health concern. Recent advancements in machine learning and deep learning technologies offer exciting prospects for improving both diagnostic and prognostic approaches in spinal injury care. This narrative review systematically explores the practical utility of these computational methods, with a focus on their application in imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI), as well as in structured clinical data. Of the 39 studies included, 34 were focused on diagnostic applications, chiefly using deep learning to carry out tasks like vertebral fracture identification, differentiation between benign and malignant fractures, and AO fracture classification. The remaining five were prognostic, using machine learning to analyze parameters for predicting outcomes such as vertebral collapse and future fracture risk. This review highlights the potential benefit of machine learning and deep learning in spinal injury care, especially their roles in enhancing diagnostic capabilities, detailed fracture characterization, risk assessments, and individualized treatment planning.

A Systematic Review and Meta-Analysis of Vertebral Artery Injury After Cervical Spine Trauma

STUDY DESIGN

Systematic Review and Meta-Analysis.

OBJECTIVE

Identify the incidence, mechanism of injury, investigations, management, and outcomes of Vertebral Artery Injury (VAI) after cervical spine trauma.

METHODS

A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines (PROSPERO-ID CRD42021295265). Three databases were searched (PubMed, SCOPUS, Google Scholar, CINAHL PLUS). Incidence of VAI, investigations to diagnose (Computed Tomography Angiography, Digital Subtraction Angiography, Magnetic Resonance Angiography), stroke incidence, and management paradigms (conservative, antiplatelets, anticoagulants, surgical, endovascular treatment) were delineated. Incidence was calculated using pooled proportions random effects meta-analysis.

RESULTS

A total of 44 studies were included (1777 patients). 20-studies (n = 503) included data on trauma type; 75.5% (n = 380) suffered blunt trauma and 24.5% (n = 123) penetrating. The overall incidence of VAI was .95% (95% CI 0.65-1.29). From the 16 studies which reported data on outcomes, 8.87% (95% CI 5.34- 12.99) of patients with VAI had a posterior stroke. Of the 33 studies with investigation data, 91.7% (2929/3629) underwent diagnostic CTA; 7.5% (242/3629) underwent MRA and 3.0% (98/3629) underwent DSA. Management data from 20 papers (n = 475) showed 17.9% (n = 85) undergoing conservative therapy, anticoagulation in 14.1% (n = 67), antiplatelets in 16.4% (n = 78), combined therapy in 25.5% (n = 121) and the rest (n = 124) managed using surgical and endovascular treatments.

CONCLUSION

VAI in cervical spine trauma has an approximate posterior circulation stroke risk of 9%. Optimal management paradigms for the prevention and management of VAI are yet to be standardized and require further research.

Concurrent Spinal Trauma in Patients with Traumatic Head Injury: A Seven-Year Retrospective Analysis

BACKGROUND Assessing spinal injuries in patients with traumatic head injuries is crucial due to their potential to alter functionality and increase mortality rates. This single-center retrospective study was conducted to understand the prevalence and characteristics of concurrent spinal injuries in adults with traumatic head injury from April 2015 to April 2022. MATERIAL AND METHODS The study incorporated demographic, clinical, traumatological, and hemodynamic data from 1,501 adult patients presenting with traumatic head injuries. Spinal injuries were identified through symptoms, physical signs, and radiological findings. RESULTS During the study period, 179 patients (12%) were reported with associated spinal injuries. These patients were predominantly male (p=0.0012), aged 65 years or above (p=0.0452), had thoracic injuries (p=0.0004), and arrived at the emergency department more than three hours post-trauma (p=0.0004). Most injuries were caused by motor vehicle accidents (p=0.0412) or falls from heights greater than 3 meters (p=0.0481). In addition, these patients had higher Abbreviated Injury Scale scores (≥2, p=0.0391), Eppendorf-Cologne Scale scores (≥2, p=0.0412), and lower systolic and diastolic blood pressure readings (p=0.0481, p=0.0412) along with lower heart rates (p=0.0482). However, no correlation was found between systolic and diastolic pressures and age among patients with spinal injuries. CONCLUSIONS This study reveals that the prevalence and severity of spinal injuries in patients with traumatic head injuries are influenced not only by demographic and clinical parameters, but also by the degree and extent of head trauma.

[Classification of continuous multilevel vertebral fractures]

Currently there is still little information about multilevel vertebral fractures (MVF), in addition to the fact that there are no classifications that help us group them in a simpler way, and guide us on their prognosis. The objective of this work is to propose a new classification of continuous type MVF, based on the number of end plates injured of the vertebral bodies and their severity, where we form four groups. A review of continuous MVF cases that we found in our hospital over a 6-year period was carried out, managing to designate 100% of the fractures, by their characteristics, to the corresponding group. In addition, we observed a better neurological prognosis in group 1. This classification is a proposal that will help us to group these injuries, that can be very varied, in only four groups; with the aim of later creating a more standardized management proposal, and knowing its neurological prognosis.

Cervical spine trauma - Evaluating the diagnostic power of CT, MRI, X-Ray and LODOX

BACKGROUND

Traumatic cervical spine (c-spine) injuries account for 10% of all spinal injuries. The c-spine is prone to injury by blunt acceleration/deceleration traumas. The Canadian C-Spine rule and NEXUS criteria guide clinical decision-making but lack consensus on imaging modality when necessary. This study aims to evaluate the sensitivity and specificity of CT, MRI, X-Ray, and, for the first time, LODOX-Statscan in identifying c-spine injuries in patients with blunt trauma and neck pain.

METHODS

We conducted a retrospective monocenter cohort study using patient data from the emergency department at Inselspital, Bern, Switzerland's largest level one trauma center. We identified patients presenting with trauma and neck pain during the recruitment period from 01.01.2012 to 31.12.2017. We included all patients that required a radiographic c-spine evaluation according to the NEXUS criteria. Certified spine surgeons reviewed each case, analyzed patient demographics, injury classification, trauma mechanism, and emergency management. The retrospective full case review was established as gold standard to decide whether the c-spine was injured. Sensitivity and specificity were calculated for CT, MRI, LODOX, and X-Ray imaging methods.

RESULTS

We identified 4996 patients, of which 2321 met the inclusion criteria. 91.3% (n = 2120) patients received a CT scan, 8.9% (n = 206) a MRI, 9.3% (n = 215) an X-ray, and 21.5% (n = 498) a LODOX scan. By retrospective case review, 186 participants were classified as injured. The sensitivity of CT was 88.6% (specificity 99%), and 89.8% (specificity 99.2%) with orthopedic surgeon consultation. MRI had a sensitivity of 88.5% (specificity of 96.9%); highlighting 14 cases correctly diagnosed as injured by MRI and misdiagnosed by CT. Projection radiography (36.4% sensitivity, 95.1% specificity) and LODOX (5.3% sensitivity, 100% specificity) were unsuitable for ruling out spinal injury.

CONCLUSION

While CT offers high sensitivity for detecting traumatic c-spine injury, MRI holds clinical significance in revealing injuries not recognized by CT in symptomatic patients. LODOX and projection radiography are insufficient for accurately ruling out c-spine injury. For patients with neurological symptoms, we recommend extended MRI use when CT scans are negative.

The changing landscape of spinal injuries: A narrative review

In the past, spinal trauma was frequent in high- and middle-income regions of the world with high rates of automobility and was considered a "young men's disease." However, over the last 2 decades, both of these factors have changed dramatically. This has had important implications for our methods of diagnosis, treatment, and the organization of care.

Spinal Cord Alignment in Patients with Thoracolumbar Burst Fracture

Objective  To evaluate the spinopelvic alignment in patients with thoracolumbar burst fracture (TBF) without neurological deficit treated nonsurgically and surgically in a tertiary reference trauma hospital.

Method  Retrospective cross-sectional study of patients with single level, type A3 and A4 AOSpine TBF only of the thoracolumbar region. Analysis of clinical data, low back pain (visual analogue scale [VAS]), Denis Pain Scale, quality of life (SF-36), sagittal (TC, TLC, LL, SVA) and spinopelvic (IP, PV, SI, PI-LL) radiographic parameters of patients treated surgically and nonsurgically.

Results A total of 50 individuals with an average age of 50 years old with a mean follow-up of 109 months (minimum of 19 and maximum of 306 months) were evaluated. There was a significant difference between treatments for the Denis Work Scale ( p  = 0.046) in favor of nonsurgical treatment. There was no significant difference between the treatments for lower back pain VAS and Denis Pain Scale ( p  = 0.468 and p  = 0.623). There was no significant difference between treatments in any of the domains evaluated with the SF-36 ( p  > 0.05). Radiographic parameters were not different between the analyzed groups; however, all radiographic parameters showed significant difference between the population considered asymptomatic, except for pelvic incidence ( p  < 0.005).

Conclusions  The spinopelvic alignment was normal in patients with TBF without neurological deficit treated nonsurgically and surgically after a minimum follow-up of 19 months. However, they presented a higher mean pelvic version and discrepancy between lumbar lordosis and pelvic incidence when compared with the reference values of the Brazilian population.

CT Scan in Subaxial Cervical Facet Injury: Is It Enough for Decision-Making?

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

Assessment of subaxial cervical facet injuries using the AO Spine Subaxial Cervical Spine Injury Classification System is based on CT scan findings. However, additional radiological evaluations are not directly considered. The aim of this study is to determine situations in which spine surgeons request additional radiological exams after a facet fracture.

METHODS

A survey was sent to AO Spine members from Latin America. The evaluation considered demographic variables, routine use of the Classification, as well as the timepoint at which surgeons requested a cervical MRI, a vascular study, and/ or dynamic radiographs before treatment of facet fractures.

RESULTS

There was 229 participants, mean age 42.9 ± 10.2 years; 93.4% were men. Orthopedic surgeons 57.6% with 10.7 ± 8.7 years of experience in spine surgery. A total of 86% used the Classification in daily practice. An additional study (MRI/vascular study/and dynamic radiographs) was requested in 53.3%/9.6%/43.7% in F1 facet injuries; 76.0%/20.1%/50.2% in F2; 89.1%/65.1%/28.4% in F3; and 94.8%/66.4%/16.6% in F4. An additional study was frequently required: F1 72.5%, F2 86.9%, F3 94.7%, and F4 96.1%.

CONCLUSIONS

Spine surgeons generally requested additional radiological evaluations in facet injuries, and MRI was the most common. Dynamic radiographs had a higher prevalence for F1/F2 fractures; vascular studies were more common for F3/F4 especially among surgeons with fewer years of experience. Private hospitals had a lower spine trauma cases/year and requested more MRI and more dynamic radiographs in F1/F2. Neurosurgeons had more vascular studies and dynamic radiographs than orthopedic surgeons in all facet fractures.

Riluzole is Effective on Spinal Decompression for Treating Acute Spinal Injury When Compared With Methylprednisolone and the Combination of Two Drugs: In Vivo Rat Model

STUDY DESIGN

Randomized controlled animal experiment.

OBJECTIVES

To determine and compare the efficacy of riluzole, MPS and the combination of two drugs in a rat model with acute spinal trauma, electrophysiologically and histopathologically.

METHODS

59 rats were divided into 4 groups as control, riluzole (6 mg/kg, every 12 hours for 7 days), MPS (30 mg/kg, 2nd and 4th hours after injury) and riluzole + MPS. Spinal trauma was created and the subjects were followed for 7 days. Electrophysiological recordings were made via neuromonitoring. The subjects were sacrificed and histopathological examination was made.

RESULTS

For the amplitude values, mean alteration in the period from the spinal cord injury to the end of the 7th day is 15.89 ± 20.00%, 210.93 ± 199.44%, 24.75% ± 10.13% increase and 18.91 ± 30.01% decrease for the control, riluzole, riluzole + MPS and MPS groups, respectively. Although the riluzole treatment group produced the greatest increase in amplitude, it was observed that no treatment provided a significant improvement compared to the control group, in terms of latency and amplitude. It was observed that there was significantly less cavitation area in the riluzole treatment group compared to the control group (P = .020). (P < .05).

CONCLUSIONS

Electrophysiologically, no treatment was found to provide significant improvement. Histopathologically, it was observed that riluzole provided significant neural tissue protection.

Diffuse Idiopathic Skeletal Hyperostosis with Severely Displaced Spine Fracture Managed with Posterior Approach Alone: Case Reports and Literature Review

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition in which minor trauma can cause extremely unstable vertebral fractures. Spinal fractures associated with DISH are prone to instability due to the large moment of lever arm and secondary neurological deterioration; hence, surgical internal fixation is considered necessary. On the other hand, some reports suggest that patients with DISH have a high osteogenic potential. In this report, we describe three patients with DISH. These patients had spinal injuries that resulted in a large gap, for which anterior fixation with bone graft would generally be considered due to comminuted fractures. However, we achieved good bony fusion with posterior fixation alone, without forcible correction.

Recommendation for changes to the guidelines of trauma patients with potential spinal injury within a regional UK ambulance trust

BACKGROUND

Spinal assessment and immobilisation has been a topic of debate for many years where, despite an emerging evidence base and the delivery of new guidance overseas, little has changed within UK pre-hospital practice. Since 2018, South East Coast Ambulance Service NHS Foundation Trust has spent time working with local trauma networks and expertise from within the region and international colleagues to develop a set of C-spine assessment and immobilisation guidelines that reflect the current best available international evidence and significant changes in international pre-hospital practice from settings such as Scandinavia and Australasia.

METHODS

A specialist group was commissioned to review the topic of pre-hospital spinal immobilisation and explore potential for evidence-based improvement. In conjunction with local trauma networks, subject matter experts and a thorough review of recent literature, a series of recommendations were made in order to improve spinal care within the authoring trust.

RESULTS

Seven recommendations were made, and an updated set of guidelines produced. These included the removal of semi-rigid collars from pre-hospital spinal immobilisation; the creation of two tiers of patients to ensure that the high-risk and low-risk populations are considered separately and an accompanying decision tool to safeguard both cohorts; an increased emphasis on the risk of spinal injury in the frail and older patient; an emphasis on spinal motion restriction rather than rigid immobilisation; an increased emphasis on self-extrication; and the use of a marker for emergency departments.

SUMMARY

An updated set of guidance has been produced using a combination of specialist and expert opinion alongside a literature review with close involvement of key stakeholders, both public and professional. The new guidance helps to ensure a patient-centred approach where each person is considered an individual with their risk of injury and management measures tailored to their specific needs.

Unstable Thoracolumbar Injuries: Factors Affecting the Decision for Short-Segment vs Long-Segment Posterior Fixation

BACKGROUND

Factors influencing the length of spinal instrumentation have been mostly evaluated in burst fractures, receiving more attention than other unstable thoracolumbar injuries. We aimed to evaluate clinical factors affecting surgical decision-making and associated complications.

METHODS

This was a multicentric retrospective cohort study. Outcomes of patients with AO Spine injury classification types B2, B3, and C operated through an open posterior-only approach were analyzed. Length of instrumentation was correlated with age, type of injury, comorbidities, level of injury, neurological status, and complications.

RESULTS

Among 439 patients, 30.3% underwent short-segment fixation (SSF) and 69.7% underwent long-segment fixation (LSF). Type C injuries were treated with LSF in 89.4% of cases (P < 0.001). On multivariate analysis, age ≤39 years (OR: 2.06), AO spine type B2 (OR: 3.58), and type B3 (OR: 7.48) were statistically significant predictors for SSF, while hypertension (OR: 4.07), upper thoracic injury (OR: 9.48), midthoracic injury (OR: 6.06), and American Spinal Injury Association Impairment Scale A (OR: 3.14) were significantly associated with LSF. Patients with SSF had fewer overall complications (27.1% vs 50.9%, P < 0.001) and were less likely to develop pneumonia (6.0% vs 18.3%, P < 0.001) and urinary tract infections (6.8% vs 16.3%, P < 0.007).

CONCLUSIONS

Unstable thoracolumbar injuries were mostly treated by LSF. Length of instrumentation was affected by the type of spinal injury, location of the injury, and neurological status. SSF was associated with lower rates of early complications than LSF.

CLINICAL RELEVANCE

The decision on the length of fixation in the surgical treatment of unstable thoracolumbar injuries is affected by different factors, and it will impact the rate of postoperative complications.

LEVEL OF EVIDENCE: 3

Direct Internal Fixation for Unstable Atlas Fractures

PURPOSE

To investigate the radiologic and clinical outcomes of direct internal fixation for unstable atlas fractures.

MATERIALS AND METHODS

This retrospective study included 12 patients with unstable atlas fractures surgically treated using C1 lateral mass screws, rods, and transverse connector constructs. Nine lateral mass fractures with transverse atlantal ligament (TAL) avulsion injury and three 4-part fractures with TAL injury (two avulsion injuries, one TAL substance tear) were treated. Radiologic outcomes included the anterior atlantodental interval (AADI) in flexion and extension cervical spine lateral radiographs at 6 months and 1 year after treatment. CT was also performed to visualize bony healing of the atlas at 6 months and 1 year. Visual Analog Scale (VAS) scores for neck pain, Neck Disability Index (NDI) values, and cervical range of motion (flexion, extension, and rotation) were recorded at 6 months after surgery.

RESULTS

The mean postoperative extension and flexion AADIs were 3.79±1.56 (mean±SD) and 3.13±1.01 mm, respectively. Then mean AADI was 3.42±1.34 and 3.33±1.24 mm at 6 months and 1 year after surgery, respectively. At 1 year after surgery, 11 patients showed bony healing of the atlas on CT images. Only one patient underwent revision surgery 8 months after primary surgery due to nonunion and instability findings. The mean VAS score for neck pain was 0.92±0.99, and the mean NDI value was 8.08±5.70.

CONCLUSION

C1 motion-preserving direct internal fixation technique results in good reduction and stabilization of unstable atlas fractures. This technique allows for the preservation of craniocervical and atlantoaxial motion.

Assessment of cervical spine CT scans by emergency physicians: A comparative diagnostic accuracy study in a non-clinical setting

OBJECTIVES

To determine and compare the diagnostic accuracy of assessing injuries on cervical spine computed tomography (CT) scans by trained emergency physicians and radiologists, both in a non-clinical setting.

METHODS

In this comparative diagnostic accuracy study, 411 cervical spine CT scans, of which 120 contained injuries (fractures and/or dislocations), were divided into 8 subsets. Eight emergency physicians received focused training and assessed 1 subset each before and after training. Four radiologists assessed 2 subsets each. Diagnostic accuracy between both groups was compared. The reference standard used was a multiverified data set, assessed by radiologists, neurosurgeons, and emergency physicians. The neurosurgeons also classified whether an "injury in need of stabilizing therapy" (IST) was present.

RESULTS

Posttraining, the emergency physicians demonstrated increased sensitivity and specificity for identifying cervical spine injuries compared to pretraining: sensitivity 88% (95% confidence interval [CI] 80% to 93%) versus 80% (95% CI 72% to 87%) and specificity 89% (95% CI 85% to 93%) versus 86% (95% CI 81% to 89%). When comparing the trained emergency physicians to the group of radiologists, no difference in sensitivity was found, 88% (95% CI 80% to 83%); however, the radiologists showed a significantly higher specificity (P < 0.01): 99% (95% CI 96% to 100%). In the 12% (15 scans) with missed injuries, emergency physicians missed more ISTs than radiologists, 6 versus 4 scans; however, this difference was not significant (P = 0.45).

CONCLUSION

After focused training and in a non-clinical setting, no significant difference was found between emergency physicians and radiologists in ruling out cervical spine injuries; however, the radiologists achieved a significantly higher specificity.

Urinary Retention as the Presenting Clinical Manifestation of Unstable Thoracic Spinal Fracture with Diffuse Idiopathic Skeletal Hyperostosis

Patients with diffuse idiopathic skeletal hyperostosis (DISH) are at high risk for unstable vertebral fracture, which can be frequently missed. An 80-year-old man with pre-existing muscle lower limb weakness due to frailty was referred from another hospital, presenting with progressive urinary retention and its related symptoms, which had been treated as a urinary tract infection at previous hospital. One week prior to our visit, he had fallen. On arrival, he appeared lethargic and unable to follow commands. He denied any back pain. Computed tomography identified a T10 fracture and dislocation associated with DISH. Although immediate surgical fixation was performed, the patient did not recover from the neurological deficits. Diagnostic delay of DISH-associated vertebral fracture can occur due to both patients' and clinicians' delayed action. We believe this case report can help clinicians recognize this potentially devastating condition.

The Isokinetic Rugby Union Physical Work Evaluation (RUPWE) protocol: Can Rugby Union Players meet the physical work demands of the game?

Background

To protect the lumbar spine from excessive forces, rugby union players need to demonstrate the work ability of the trunk extensors and flexors to meet the physical demands.

Aim

To measure and evaluate whether rugby union players were able to meet the imposed physical work demand, considering limitations, tolerances and resistance to fatigue, using isokinetic dynamometry for trunk extensors (TE) and trunk flexors (TF).

Methods

Fifty-five male players, between the ages of 18 and 23 years, participated in the study. All participants completed a PAR-Q (pre-activity risk) questionnaire before the isokinetic testing. Their height was between 1.80 ± 0.67 m and body mass was 86.0 ± 17.5 kg. Participants were subjected to a newly designed protocol using the Biodex Isokinetic System 3 Dynamometer, called the Rugby Union Physical Work Evaluation (RUPWE).

Results

There was a significant difference between the forwards' trunk extensor peak torque to body weight 488% ± 119% and the trunk flexor peak torque to body weight 289% ± 73%. Furthermore, there was a large effect size between trunk extensor and trunk flexor muscle performance for the forwards (d =2.0) and backs (d =1.9) for peak torque to body weight. Spearman's rank-order correlations (r_s) showed a moderate negative correlation for the forwards between trunk extensor peak torque to body weight and time to peak torque, (r_s = -0.4; p=0.018). There is a strong negative correlation for the backs between trunk extensor peak torque to body weight and time to peak torque, (r_s = -0.6; p=0.003).

Conclusion

The physical work evaluation protocol can be used as a screening tool for rugby players as it measures the extensive mechanical load placed on the lumbar region. This has the potential to evaluate their athletic performance for the demands of tackling and scrumming.

Cervical Spine Imaging and Injuries in Young Children With Non-Motor Vehicle Crash-Associated Traumatic Brain Injury

OBJECTIVES

The aim of this study was to evaluate cervical magnetic resonance imaging (MRI) and computed tomography (CT) practices and cervical spine injuries among young children with non-motor vehicle crash (MVC)-associated traumatic brain injury (TBI).

METHODS

We performed a retrospective study of a stratified, systematic random sample of 328 children younger than 2 years with non-MVC-associated TBI at 4 urban children's hospitals from 2008 to 2012. We defined TBI etiology as accidental, indeterminate, or abuse. We reported the proportion, by etiology, who underwent cervical MRI or CT, and had cervical abnormalities identified.

RESULTS

Of children with non-MVC-associated TBI, 39.4% had abusive head trauma (AHT), 52.2% had accidental TBI, and in 8.4% the etiology was indeterminate. Advanced cervical imaging (CT and/or MRI) was obtained in 19.1% of all children with TBI, with 9.3% undergoing MRI and 11.7% undergoing CT. Cervical MRI or CT was performed in 30.9% of children with AHT, in 11.7% of accidental TBI, and in 10.7% of indeterminate-cause TBI. Among children imaged by MRI or CT, abnormal cervical findings were found in 22.1%, including 31.3% of children with AHT, 7.1% of children with accidental TBI, and 0% of children with indeterminate-cause TBI. Children with more severe head injuries who underwent cervical imaging were more likely to have cervical injuries.

CONCLUSIONS

Abusive head trauma victims appear to be at increased risk of cervical injuries. Prospective studies are needed to define the risk of cervical injury in children with TBI concerning for AHT and to inform development of imaging guidelines.

Music tuned to 432 Hz versus music tuned to 440 Hz for improving sleep in patients with spinal cord injuries: a double-blind cross-over pilot study

BACKGROUND AND AIM OF THE WORK

Among people with spinal cord injuries, sleep disorders are considered one of the top well-being priorities. Some studies suggest that listening to music promotes sleep and improves its quality. These studies usually used music standardised at the frequency of 440 Hz. The aim of the present study is to compare the effects of listening to music tuned to 440 Hz and music tuned to 432 Hz on sleep in patients with spinal cord injuries.

METHODS

Double-blind cross-over pilot study in a single Italian Spinal Unit. 12 patients with spinal injuries were provided with mp3 players loaded with their favourite music tuned to 440 Hz or 432 Hz. They were invited to listen to music for 30 minutes each day, in the two periods of the study. "Sleep Scale for Medical Study" modified for this study, and the "Perceived Stress Scale" were chosen.

RESULTS

The participants were eight males (mean age =58.12, SD ±13.62), and four females (mean age =56.25, SD ±14.17). Five were quadriplegics and seven were paraplegics. Listening times and wash-out periods were variable. The stress decreased, but not significantly, with listening to music at both frequencies. After listening to music at 432 Hz there was a significant improvement in sleep scores (+3.6, p=0.02), while there was no improvement in sleep scores listening to music at 440 Hz (-1.50, p=0.34).

CONCLUSIONS

The results suggest that further studies on music interventions at 432 Hz should be performed. It is advisable to increase sample sizes and use a range of different research methods.

Schwann Cell-Like Cells: Origin and Usability for Repair and Regeneration of the Peripheral and Central Nervous System

Functional recovery after neurotmesis, a complete transection of the nerve fiber, is often poor and requires a surgical procedure. Especially for longer gaps (>3 mm), end-to-end suturing of the proximal to the distal part is not possible, thus requiring nerve graft implantation. Artificial nerve grafts, i.e., hollow fibers, hydrogels, chitosan, collagen conduits, and decellularized scaffolds hold promise provided that these structures are populated with Schwann cells (SC) that are widely accepted to promote peripheral and spinal cord regeneration. However, these cells must be collected from the healthy peripheral nerves, resulting in significant time delay for treatment and undesired morbidities for the donors. Therefore, there is a clear need to explore the viable source of cells with a regenerative potential similar to SC. For this, we analyzed the literature for the generation of Schwann cell-like cells (SCLC) from stem cells of different origins (i.e., mesenchymal stem cells, pluripotent stem cells, and genetically programmed somatic cells) and compared their biological performance to promote axonal regeneration. Thus, the present review accounts for current developments in the field of SCLC differentiation, their applications in peripheral and central nervous system injury, and provides insights for future strategies.

Complex Fractures of the Sacrum with Spinopelvic Dissociation Treated Surgically with Iliolumbar Fixation

Objective  To analyze a series of cases of complex fractures of the sacrum with spinopelvic dissociation surgically treated with iliolumbar fixation, and to review the existing medical literature.

Methods  For the analysis, the medical records of the cases operated using the Schildhauer et al technique for fixation were retrospectively evaluated, and followed up for at least 12 months. The functional results were assessed using the visual analog scale (VAS) for pain and the Oswestry disability index, version 2.0. The data were compared with those of the existing medical literature.

Results  Six cases were analyzed, four of which evolved with moderate disability, one, with minimal disability, and one, with severe disability. Three cases that presented neurological deficits obtained significant improvement. Only one case evolved with pulmonary thromboembolic complications.

Conclusion  The Schildhauer et al technique is an efficient technique for the fixation of complex sacral fractures with spinopelvic dissociation. The patients evolved with good functional results. Early weight-bearing has been shown to be safe with the use of this treatment.

International Comparison of Vocational Rehabilitation for Persons With Spinal Cord Injury: Systems, Practices, and Barriers

Background: Employment rates among people with spinal cord injury or spinal cord disease (SCI/D) show considerable variation across countries. One factor to explain this variation is differences in vocational rehabilitation (VR) systems. International comparative studies on VR however are nonexistent. Objectives: To describe and compare VR systems and practices and barriers for return to work in the rehabilitation of persons with SCI/D in multiple countries. Methods: A survey including clinical case examples was developed and completed by medical and VR experts from SCI/D rehabilitation centers in seven countries between April and August 2017. Results: Location (rehabilitation center vs community), timing (around admission, toward discharge, or after discharge from clinical rehabilitation), and funding (eg, insurance, rehabilitation center, employer, or community) of VR practices differ. Social security services vary greatly. The age and preinjury occupation of the patient influences the content of VR in some countries. Barriers encountered during VR were similar. No participant mentioned lack of interest in VR among team members as a barrier, but all mentioned lack of education of the team on VR as a barrier. Other frequently mentioned barriers were fatigue of the patient (86%), lack of confidence of the patient in his/her ability to work (86%), a gap in the team's knowledge of business/legal aspects (86%), and inadequate transportation/accessibility (86%). Conclusion: VR systems and practices, but not barriers, differ among centers. The variability in VR systems and social security services should be considered when comparing VR study results.

Prolonged Electro-muscular Incapacitation in a Porcine Model Causes Spinal Injury

Conducted electrical weapons are designed to cause temporary electro-muscular incapacitation (EMI) without significant injury. The objective of this study was to assess the risk and cause of spinal injury due to exposure to a benchtop EMI device. Porcine subjects were exposed to 19 and 40 Hz electrical stimuli for a prolonged duration of 30 sec. X-ray imaging, necropsy, and accelerometry found that lumbosacral spinal fractures occurred in at least 89% of all subjects, regardless of the stimulus group, and were likely caused by musculoskeletal fatigue-related stress in the lumbosacral spine. Spinal fractures occurred in the porcine model at an unusually high rate compared to human. This may be due to both the prolonged duration of electrical stimulation and significant musculoskeletal differences between humans and pigs, which suggests that the porcine model is not a good model of EMI-induced spinal fracture in humans.

AOSpine-Spine Trauma Classification System: The Value of Modifiers: A Narrative Review With Commentary on Evolving Descriptive Principles

STUDY DESIGN

Narrative review.

OBJECTIVES

To describe the current AOSpine Trauma Classification system for spinal trauma and highlight the value of patient-specific modifiers for facilitating communication and nuances in treatment.

METHODS

The classification for spine trauma previously developed by The AOSpine Knowledge Forum is reviewed and the importance of case modifiers in this system is discussed.

RESULTS

A successful classification system facilitates communication and agreement between physicians while also determining injury severity and provides guidance on prognosis and treatment. As each injury may be unique among different patients, the importance of considering patient-specific characteristics is highlighted in this review. In the current AOSpine Trauma Classification, the spinal column is divided into 4 regions: the upper cervical spine (C0-C2), subaxial cervical spine (C3-C7), thoracolumbar spine (T1-L5), and the sacral spine (S1-S5, including coccyx). Each region is classified according to a hierarchical system with increasing levels of injury or instability and represents the morphology of the injury, neurologic status, and clinical modifiers. Specifically, these clinical modifiers are denoted starting with M followed by a number. They describe unique conditions that may change treatment approach such as the presence of significant soft tissue damage, uncertainty about posterior tension band injury, or the presence of a critical disc herniation in a cervical bilateral facet dislocation. These characteristics are described in detail for each spinal region.

CONCLUSIONS

Patient-specific modifiers in the AOSpine Trauma Classification highlight unique clinical characteristics for each injury and facilitate communication and treatment between surgeons.

Reliability and Validity of the AOSpine Thoracolumbar Injury Classification System: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The AOSpine thoracolumbar injury classification system (ATLICS) is a relatively simple yet comprehensive classification of spine injuries introduced in 2013. This systematic review summarizes the evidence on measurement properties of this new classification, particularly the reliability and validity of the main morphologic injury types with and without inclusion of the subtypes.

METHODS

A literature search was performed using PubMed and Embase in September 2016. A revised version of the COSMIN checklist was used for evaluation of the quality of studies. Two independent reviewers performed all steps of the review.

RESULTS

Nine articles were included in the final review, all of which evaluated the reliability of the ATLICS and had a fair methodological quality. The reliability of the modifiers was unknown. Overall, the quality of evidence for reliability of the morphologic and neurologic classification sections was low. However, there was moderate evidence for poor interobserver reliability of the morphologic classification when all subtypes were included, and moderate evidence for good intraobserver reliability with exclusion of subtypes. The reliability of the morphologic classification was independent of the observer's experience and cultural background.

CONCLUSIONS

ATLICS represents the most current system for evaluation of thoracolumbar injuries. Based on this review, further studies with robust methodological quality are needed to evaluate the measurement properties of ATLICS. Shortcomings of the reliability studies are discussed.

[Functional state of spinal cord and its radices in patients with thoracic and lumbar spine injuries]

AIM

To estimate the character of neurophysiological monitoring in patients with thoracic and lumbar spine injuries at different treatment stages.

MATERIAL AND METHODS

Thirty-eight patients with non-complicated (22 patients, group 1) and complicated (16 patients, group 2) thoracic and lumbar spine injuries underwent electroneuromyography (ENM) and transcranial magnetic stimulation (TMS). The examination was performed at early (up to 2 weeks) and later (more than 1 month) post-injury periods, before the operation and on the 10^th day after decompressing-stabilizing interventions.

RESULTS

Before the operation, 71.4% patients of group 1 had ENM-signs of suppressed motor neuron activity in L5 segment of the spinal cord with peroneal nerve axonopathy. The most significant changes in ENM-indexes were observed in medullary channel stenosis of more than 30%. TMS parameters in group 1 were normal while in the 2^nd group, EMN and TMS results before the operation demonstrated preserved motor neuron activity at the injury level despite gross neurological symptoms and 100% of medullary channel lumen deficit. In the postoperative period, ENM and TMS revealed no definite negative dynamics in patients of both groups. Patients with locomotor disorders, who underwent surgery at late post-injury periods, showed neurophysiological dynamics on the 10^th day postoperatively. Low amplitude motor evoked potentials (kMEP), which were not present before, suggested initial signs of conductibility restoration (in 22% of patients) that proved the effectiveness of decompressive interventions in the long-term post-injury period.

CONCLUSION

ENM- and TMS monitoring in patients with complicated and non-complicated injuries of thoracic and lumbar spine allowed revealing the positive influence of decompressing-stabilizing operations conducted both at early and late post-injury periods on the state of spinal cord conductibility and segmental apparatus.

Back stabber: ladder fall causing traumatic aortic transection

A 68-year-old man presented with back pain after falling from a ladder and was found to have anterolisthesis of thoracic vertebrae T11-12 with secondary focal aortic injury and disruption of the aortic wall. This was successfully repaired using thoracic endovascular aortic repair (TEVAR) followed by spinal fusion with excellent result.

Removal of the Long Spine Board From Clinical Practice: A Historical Perspective

Since the early 1970s, initial management of patients with suspected spinal injuries has involved the use of a cervical collar and long spine board for full immobilization, which was thought to prevent additional injury to the cervical spine. Despite a growing body of literature demonstrating the detrimental effects and questionable efficacy of spinal immobilization, the practice continued until 2013, when the National Association of EMS Physicians issued a position statement calling for a reduction in the use of spinal immobilization and a shift to spinal-motion restriction. This article examines the literature that prompted the change in spinal-injury management and the virtual elimination of the long spine board as a tool for transport.

Spinal cord injury in elderly patients admitted to a tertiary hospital

BACKGROUND

Spinal cord injury (SCI) has a negative impact on quality of life and healthcare costs. In recent years with the age pyramid inversion, there has been a high prevalence of SCI in the elderly. These patients must be studied in order to invest in the prevention and treatment of SCI in these patients.

OBJECTIVE

To identify the characteristics and clinical aspects of spinal cord injury (SCI) in the elderly.

METHODS

Retrospective study of elderly patients (≥ 60 years of age) with a clinical diagnosis of SCI. Clinical and socio-demographic variables were collected from medical records.

RESULTS

Sixty-two elderly patients were studied (56% men). The patients were analyzed according to gender. Women presented compression fractures associated with thoracolumbar transition, while men presented with listhesis associated with cervical lesions and increased complications. It was found that the need for surgical intervention was higher in men. Among many characteristics that differed between the elderly and younger people (< 60 years; n = 259), in the morphological diagnosis, we observed that compression fractures and dislocation fractures were more highly associated with ages ≥ 60 and < 60, respectively. After SCI, the elderly have a higher risk for late hemodynamic instability.

CONCLUSION

Elderly individuals with SCI have distinct characteristics and clinical factors related to gender and age.

New Immobilization Guidelines Change EMS Critical Thinking in Older Adults With Spine Trauma

OBJECTIVE

The impact of immobilization techniques on older adult trauma patients with spinal injury has rarely been studied. Our advisory group implemented a change in the immobilization protocol used by emergency medical services (EMS) professionals across a region encompassing 9 trauma centers and 24 EMS agencies in a Rocky Mountain state using a decentralized process on July 1, 2014. We sought to determine whether implementing the protocol would alter immobilization methods and affect patient outcomes among adults ≥60 years with a cervical spine injury.

METHODS

This was a 4-year retrospective study of patients ≥60 years with a cervical spine injury (fracture or cord). Immobilization techniques used by EMS professionals, patient demographics, injury characteristics, and in-hospital outcomes were compared before (1/1/12-6/30/14) and after (7/1/14-12/31/15) implementation of the Spinal Precautions Protocol using bivariate and multivariate analyses.

RESULTS

Of 15,063 adult trauma patients admitted to nine trauma centers, 7,737 (51%) were ≥60 years. Of those, 237 patients had cervical spine injury and were included in the study; 123 (51.9%) and 114 (48.1%) were transported before and after protocol implementation, respectively. There was a significant shift in the immobilization methods used after protocol implementation, with less full immobilization (59.4% to 28.1%, p < 0.001) and an increase in the use of both a cervical collar only (8.9% to 27.2%, p < 0.001) and not using any immobilization device (15.5% to 31.6%, p = 0.003) after protocol implementation. While the proportion of patients who only received a cervical collar increased after implementing the Spinal Precautions Protocol, the overall proportion of patients who received a cervical collar alone or in combination with other immobilization techniques decreased (72.4% to 56.1%, p = 0.01). The presence of a neurological deficit (6.5% vs. 5.3, p = 0.69) was similar before and after protocol implementation; in-hospital mortality (adjusted odds ratio = 0.56, 95% confidence interval: 0.24-1.30, p = 0.18) was similar post-protocol implementation after adjusting for injury severity.

CONCLUSIONS

There were no differences in neurologic deficit or patient disposition in the older adult patient with cervical spine trauma despite changes in spinal restriction protocols and resulting differences in immobilization devices.

[Analysis of the Injury-disease Relationship between Spondylolysis and Trauma in 26 Forensic Identifications]

OBJECTIVES

To expound the injury-disease relationship between spondylolysis and trauma for the points of forensic identification.

METHODS

Total 26 cases of spondylolysis were collected and the characteristics of this disease such as age, accompanied symptoms, treatment and injury manner were discussed.

RESULTS

The causal relationship existed between trauma and injury consequence in 2 appraised individuals and both of them aged less than 50 years old. The injury manners of both were high-energy injury with combined injury and these 2 patients were treated by operation.

CONCLUSIONS

The analysis of injury-disease relationship between spondylolysis and trauma should be paid attention in the middle-young age under 50 years old. More importantly, the injury-disease relationship should be analyzed in the patients who chose operative treatment.

Angiographic and Clinical Characteristics of Thoracolumbar Spinal Epidural and Dural Arteriovenous Fistulas

BACKGROUND AND PURPOSE

The purpose of this study is to compare the angiographic and clinical characteristics of spinal epidural arteriovenous fistulas (SEAVFs) and spinal dural arteriovenous fistulas (SDAVFs) of the thoracolumbar spine.

METHODS

A total of 168 cases diagnosed as spinal dural or extradural arteriovenous fistulas of the thoracolumbar spine were collected from 31 centers. Angiography and clinical findings, including symptoms, sex, and history of spinal surgery/trauma, were retrospectively reviewed. Angiographic images were evaluated, with a special interest in spinal levels, feeders, shunt points, a shunted epidural pouch and its location, and drainage pattern, by 6 readers to reach a consensus.

RESULTS

The consensus diagnoses by the 6 readers were SDAVFs in 108 cases, SEAVFs in 59 cases, and paravertebral arteriovenous fistulas in 1 case. Twenty-nine of 59 cases (49%) of SEAVFs were incorrectly diagnosed as SDAVFs at the individual centers. The thoracic spine was involved in SDAVFs (87%) more often than SEAVFs (17%). Both types of arteriovenous fistulas were predominant in men (82% and 73%) and frequently showed progressive myelopathy (97% and 92%). A history of spinal injury/surgery was more frequently found in SEAVFs (36%) than in SDAVFs (12%; P=0.001). The shunt points of SDAVFs were medial to the medial interpedicle line in 77%, suggesting that SDAVFs commonly shunt to the bridging vein. All SEAVFs formed an epidural shunted pouch, which was frequently located in the ventral epidural space (88%) and drained into the perimedullary vein (75%), the paravertebral veins (10%), or both (15%).

CONCLUSIONS

SDAVFs and SEAVFs showed similar symptoms and male predominance. SDAVFs frequently involve the thoracic spine and shunt into the bridging vein. SEAVFs frequently involve the lumbar spine and form a shunted pouch in the ventral epidural space draining into the perimedullary vein.

Atlantoaxial Rotatory Subluxation in Children

OBJECTIVES

Pediatric cervical injuries are uncommon. This study was to describe injury circumstances, clinical findings, and management among children diagnosed with atlantoaxial rotatory subluxation (AARS) to aid in its recognition and management.

METHODS

Subanalysis of a large case-control study from January 2000 to December 2004 in 17 hospitals in the Pediatric Emergency Care Applied Research Network was performed. Cases were children younger than 16 years with AARS after blunt trauma (n = 55); controls were (a) children with other cervical spine injuries (other CSI, n = 485) and (b) those with normal imaging of the cervical spine (non-CSI, n = 1060).

RESULTS

Children with AARS were younger (mean [SD] age, 7.7 [3.8] vs 10.7 [4.6]; Wilcoxon P < 0.01). Falls accounted for 36% of injuries; there were no diving mechanisms (vs other CSI, falls 19%, Fisher exact P < 0.01, and diving 7%, P = 0.04). Children with AARS sought medical care more than 24 hours after the injury event (21% vs 1% for non-CSI controls, P < 0.01). Clinical findings associated with AARS included neck pain (67%) and torticollis (57%) versus other CSI, pain (47%) and torticollis (5%, P < 0.01) for each, and versus non-CSI controls, pain (33%) and torticollis (6%, P < 0.01) for each. Management of AARS included no intervention (n = 6, 11%), soft or rigid collar only (n = 24, 44%), traction (n = 14, 25%), halo (n = 9, 16%), internal fixation (n = 2, 4%), and varied across institutions (P = 0.02).

CONCLUSIONS

Children with AARS often have a delayed presentation with neck pain and torticollis; falls are a common injury mechanism. Treatment varied across institutions. Further work is needed to identify optimal management.

Classifying thoracolumbar fractures: role of quantitative imaging

This article describes different types of vertebral fractures that affect the thoracolumbar spine and the most relevant contributions of the different classification systems to vertebral fracture management. The vertebral fractures types are based on the three columns model of Denis that includes compression, burst, flexion-distraction and fracture-dislocation types. The most recent classifications systems of these types of fractures are reviewed, including the Thoracolumbar Injury Classification and Severity score (TLICS) and the Arbeitsgemeinschaft für Osteosynthesefragen Spine Thoracolumbar Injury Classification and Severity score (AOSpine-TLICS). Correct classification requires a quantitative imaging approach in which several measurements determine TLICS or AOSpine-TLICS grade. If the TLICS score is greater than 4, or the AOSpine-TLICS is greater than 5, surgical management is indicated. In this review, the most important imaging findings and measurements on radiography, multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) are described. These include degree of vertebral wedging and percentage of vertebral height loss in compression fractures, degree of interpedicular distance widening and spinal canal stenosis in burst fractures, and the degree of vertebral translation or interspinous widening in more severe fractures types, such as flexion-distraction and fracture-dislocation. These findings and measurements are illustrated with schemes and cases of our archives in a didactic way.

Hospital Variation in Cervical Spine Imaging of Young Children With Traumatic Brain Injury

OBJECTIVE

Cervical imaging practices are poorly understood in young children with traumatic brain injury (TBI). We therefore sought to identify child-level and hospital-level factors associated with performance of cervical imaging of children with TBI from falls and abusive head trauma (AHT) and to describe across-hospital variation in cervical imaging performance. We hypothesized that imaging decisions would be influenced by hospital volume of young injured children.

METHODS

We performed a retrospective study of children younger than 2 years of age with TBI from 2009 to 2013 in the Premier Perspective Database. After adjustment for observed patient characteristics, we evaluated variation in advanced cervical imaging (computed tomography or magnetic resonance imaging) in children with AHT and TBI from falls.

RESULTS

Of 2347 children with TBI, 18.7% were from abuse and 57.1% were from falls. Fifteen percent of children with TBI underwent advanced cervical imaging. Moderate or severe head injuries were associated with increased odds of cervical imaging in AHT (odds ratio 7.10; 95% confidence interval 2.75, 18.35) and falls (odds ratio 2.25; 95% confidence interval 1.19, 4.27). There was no association between annual hospital volume of injured children and cervical imaging performance. The adjusted probability of imaging across hospitals ranged from 4.3% to 84.3% in AHT and 3.1 to 39.0% in TBI from falls (P < .001).

CONCLUSIONS

These results highlight variation across hospitals in adjusted probability of cervical imaging in AHT (nearly 20-fold) and TBI from falls (over 10-fold) not explained by observed patient characteristics. This variation suggests opportunities for further research to inform imaging practices.

Timing of Physical Therapy Initiation for Nonsurgical Management of Musculoskeletal Disorders and Effects on Patient Outcomes: A Systematic Review

STUDY DESIGN

Systematic review.

BACKGROUND

Current US practice guidelines suggest an initial "wait-and-see" approach following onset of musculoskeletal pain, particularly for spinal pain. Several studies suggest that early, compared with delayed, initiation of physical therapy for musculoskeletal conditions may decrease health costs and improve outcomes.

OBJECTIVE

To compare early and delayed initiation of physical therapy for individuals with musculoskeletal conditions and to assess effects on patient-important outcomes and cost.

METHODS

MEDLINE (Ovid), CINAHL (EBSCO), Web of Science, and PEDro were the data sources. We included studies that compared early and delayed initiation of physical therapy for patients with musculoskeletal disorders. Studies in which early and delayed interventions differed were excluded. Two independent reviewers extracted study characteristics and outcomes, and determined eligibility and quality through consensus with a third reviewer. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in summary conclusions. Standardized effect sizes (d) and odds ratios were calculated to assess the effect strength of early versus delayed physical therapy for each included study.

RESULTS

Of the 3855 articles initially screened, 14 studies were included. The majority of articles studied low back pain (only 2 articles studied cervical pain). For spinal pain, there was low-quality evidence that early versus delayed physical therapy was associated with decreased cost and decreased frequency of opioid prescriptions, advanced imaging, and surgeries without compromising patient-important outcomes. One subgroup analyzed showed improved function/disability with early physical therapy in an occupational health setting.

CONCLUSION

Although there were consistent results across studies favoring early physical therapy for decreased cost and medical utilization, quality was limited. Preliminary evidence suggests that early physical therapy may decrease cost without compromising outcomes. The primary limitation of the current research on this topic is in study design. Additional high-quality research involving prospective randomized designs and economic impact analyses is required to further investigate the outcomes associated with early initiation of physical therapy.

LEVEL OF EVIDENCE

Therapy, level 1a.

Prehospital Spinal Immobilization: Effect of Effort on Kinematics of Voluntary Head-neck Motion Assessed using Accelerometry

INTRODUCTION

Standards for immobilizing potentially spine-injured patients in the prehospital environment are evolving. Current guidelines call for more research into treatment practices. Available research into spinal immobilization (SI) reveals a number of limitations.

PROBLEM

There are currently few techniques for measuring head and neck motion that address identified limitations and can be adapted to clinically relevant scenarios. This study investigates one possible method.

METHODS

Study participants were fitted with miniaturized accelerometers to record head motion. Participants were exposed to three levels of restraint: none, cervical-collar only, and full immobilization. In each condition, participants were instructed to move in single planes, with multiple iterations at each of four levels of effort. Participants were also instructed to move continuously in multiple planes, with iterations at each of three levels of simulated patient movement. Peak and average displacement and acceleration were calculated for each immobilization condition and level of effort. Comparisons were made with video-based measurement. Participant characteristics also were tracked.

RESULTS

Acceleration and displacement of the head increased with effort and decreased with more restraint. In some conditions, participants generated measurable acceleration with minimal displacement. Continuous, multi-dimensional motions produced greater displacement and acceleration than single-plane motions under similar conditions.

CONCLUSION

Study results suggest a number of findings: acceleration complements displacement as a measure of motion in potentially spine-injured patients; participant effort has an effect on outcome measures; and continuous, multi-dimensional motion can produce results that differ from single-plane motions. Miniaturized accelerometers are a promising technology for future research to investigate these findings in realistic, clinically relevant scenarios.

The Dens: Normal Development, Developmental Variants and Anomalies, and Traumatic Injuries

Accurate interpretation of cervical spine imagining can be challenging, especially in children and the elderly. The biomechanics of the developing pediatric spine and age-related degenerative changes predispose these patient populations to injuries centered at the craniocervical junction. In addition, congenital anomalies are common in this region, especially those associated with the axis/dens, due to its complexity in terms of development compared to other vertebral levels. The most common congenital variations of the dens include the os odontoideum and a persistent ossiculum terminale. At times, it is necessary to distinguish normal development, developmental variants, and developmental anomalies from traumatic injuries in the setting of acute traumatic injury. Key imaging features are useful to differentiate between traumatic fractures and normal or variant anatomy acutely; however, the radiologist must first have a basic understanding of the spectrum of normal developmental anatomy and its anatomic variations in order to make an accurate assessment. This review article attempts to provide the basic framework required for accurate interpretation of cervical spine imaging with a focus on the dens, specifically covering the normal development and ossification of the dens, common congenital variants and their various imaging appearances, fracture classifications, imaging appearances, and treatment options.

The effectiveness of the nationwide BokSmart rugby injury prevention program on catastrophic injury rates

Rugby Union ("rugby") participants have a higher than average risk of injury compared with participants of other popular team sports. BokSmart, a nationwide injury prevention program was launched in South Africa in mid-2009, with the goal of reducing catastrophic head/neck (serious) injuries in players. The program provides injury prevention information to coaches and referees. This study investigated if BokSmart has been associated with a reduction in these injuries. The BokSmart program collected data on all South African rugby-related serious injuries since 2008. Using a Poisson regression, injury numbers were compared pre-BokSmart (2008-2009) to the years post-implementation (2010-2013). Player numbers were assumed to be constant throughout this evaluation: junior = 529,483; senior = 121,663. In junior players, the "post-BokSmart" period had 2.5 less annual serious injuries than "pre-BokSmart" (incidence rate ratio: 0.6, 95% confidence interval: 0.5-0.7, P < 0.000). In contrast, there was no significant difference in these periods in seniors. The absence of effect in seniors may be a result of fewer players or of differences in effectiveness of BokSmart in this group--future studies should investigate these questions.

Mortality profile of patients with traumatic spinal injuries at a level I trauma care centre in India

BACKGROUND & OBJECTIVES

There is no national spinal trauma registry available in India at present and the research on epidemiology of these injuries is also very limited. The purpose of this study was to describe the mortality profile of patients with spinal injuries brought to a level I trauma centre in India, and to understand the predictive factors which identify patients at an increased risk of spinal trauma mortality.

METHODS

Retrospective data were collected from computerized patients records and autopsy reports maintained in the department of Forensic Medicine. All the cases with spinal injuries whether in isolation or as a part of polytrauma were reviewed. A total of 341 such cases were identified between January 2008 to December 2011. The demographic data, type of trauma, duration of survival, body areas involved, level of spinal injury and associated injuries if any, were recorded.

RESULTS

There were 288 (84.45%) males and 53 (15.55%) females. Most victims (73%) were between 25 and 64 yr of age, followed by young adults between 16 and 24 yr (19.35%). Male: female ratio was 5.4:1. Fifty five per cent cases had spinal injuries in isolation. Injury to the cervical spine occurred in 259 (75.95%) patients, thoracic spine in 56 (16.42%) and thoraco-lumbar spine in 26 (7.62%) patients. The commonest cause of injury was high energy falls (44.28%), followed by road traffic accidents (41.93%). The majority of deaths (51.6%) occurred in the phase IV (secondary to tertiary complications of trauma, i.e. >1 wk). Forty patients died in phase I (brought dead or surviving <3 h), 55 in phase II (>3 to 24 h) and 70 in phase III (> 24 h to 7 days).

INTERPRETATION & CONCLUSIONS

Our data suggest that there is an urgent need to take steps to prevent major injuries, strengthen the pre-hospital care, transportation network, treatment in specialized trauma care units and to improve injury surveillance and the quality of data collected which can guide prevention efforts to avoid loss of young active lives.

Spinal clearance in unconscious children following traumatic brain injury

Spinal clearance in unconscious children following traumatic brain injury is an area of controversy. The risk of significant injury in this high-risk group needs to be balanced against that of prolonged spinal immobilization and all its implications. No national or international guideline exists to aid clinicians faced with such a scenario. This article reviews traumatic spinal injury in children looking at prevalence, risk factors, anatomical considerations, and radiological investigation. Spinal immobilization is discussed along with the use of appropriate and targeted radiological investigations to aid clearance.

Posterior tension band wiring and instrumentation for thoracolumbar flexion-distraction injuries

PURPOSE

To evaluate treatment outcome of tension band wiring followed by posterior spinal fusion and instrumentation for thoracolumbar flexiondistraction injury (FDI).

METHODS

36 men and 12 women aged 21 to 56 (mean, 36) years underwent tension band wiring followed by posterior spinal fusion and instrumentation using pedicular screws for FDI of the thoracolumbar spine. The injured vertebral levels were T11 (n=2), T12 (n=12), T11-T12 (n=1), T12-L1 (n=1), L1 (n=28), and L2 (n=4). Anterior vertebral body height and kyphosis were measured before and after surgery. Neurologic status was assessed using the American Spinal Injury Association (ASIA) scale. The Oswestry Disability Index questionnaire and visual analogue scale for pain were also used.

RESULTS

The mean follow-up was 38 (range, 26-72) months. At final follow-up, the mean visual analogue scale for pain was 1.7, and the median Oswestry Disability Index was 4% (range, 0-32%). The mean anterior vertebral body height improved from 20.5 to 38.8 mm (p<0.001). The mean kyphosis improved from 20.4º to 1.5º (p<0.001). Four patients had persistent neurologic deficit: ASIA scale C (n=2) and D (n=2); their ASIA scales improved by one grade. All patients returned to their original work at 6 months. There were no intra-operative complications or implant failures.

CONCLUSION

Posterior tension band wiring followed by posterior spinal fusion and instrumentation for thoracolumbar FDIs achieved good outcome.

The prevalence and clinical importance of incidental soft-tissue findings in cervical CT scans of trauma population

OBJECTIVES

To define the age-related prevalence of incidental soft-tissue findings in cervical CT scans of a trauma population and to investigate their clinical importance.

METHODS

The original diagnostic radiology reports and the CT images of the 357 patients with cervical trauma were retrospectively evaluated. Incidental soft-tissue findings were investigated. All findings were grouped according to age. The findings were classified based on their clinical importance into three categories: Category 1: no clinical importance, Category 2: possible clinical importance requiring further investigation and Category 3: obvious clinical importance. In addition, the medical records of the patients were investigated. The follow-up ratio of the pathologies mentioned in the original radiology report was recorded.

RESULTS

The most frequently encountered findings in Categories 2 and 3 were carotid artery calcification (n = 89, 24.9%) and tonsillolith (n = 115, 32.2%), respectively. The reporting ratio in the original reports of Categories 1, 2 and 3 findings was 1.1% (n = 4), 9% (n = 27) and 34.5% (n = 64), respectively. No further investigations and follow-up was accomplished for Category 1 lesions, whereas 11.1% of Category 2 and 35.9% of Category 3 lesions were subjected to further investigations and follow-up.

CONCLUSIONS

The cervical CT scans of trauma patients reveal many clinically important soft-tissue incidental findings. Cervical region incidental findings may be followed up on an outpatient basis, rarely being of life-threatening value. The ratio of reporting and follow-up of incidental findings increases parallel to the clinical importance of the lesions.

The making of Ludwig Guttmann

Ludwig Guttmann was the founder of the National Spinal Injury Centre at Stoke Mandeville Hospital, the first successful unit in Europe to treat spinal injury patients. He also founded the paraplegic sports movement. This article is based on Guttmann's unpublished autobiography and 25 years of personal experience. He was born in Germany where he was trained in neurology, neurosurgery, rehabilitation and research by Otfrid Foerster. Guttmann fled Germany in 1939. German medicine led the World and Guttmann applied his training to the treatment of spinal injury patients in the United Kingdom.

The precision, accuracy and validity of detecting posterior ligamentous complex injuries of the thoracic and lumbar spine: a critical appraisal of the literature

PURPOSE

The diagnostic assessment and prognostic value of the posterior ligamentous complex (PLC) remains a controversial topic in the management of patients with thoracolumbar spinal injury. The purpose of this review was to critically appraise the literature and present an overview of the: (1) precision, (2) accuracy, and (3) validity of detecting PLC injuries in patients with thoracic and lumbar spine trauma.

METHODS

Studies evaluating the precision, accuracy and/or validity of detecting and managing PLC injuries in patients with thoracic and/or lumbar spine injuries were searched through the Medline database (1966 to September 2011). References were retrieved and evaluated individually and independently by two authors.

RESULTS

Twenty-one eligible studies were identified. Few studies reported the use of countermeasures for sampling and measurement bias. In nine agreement studies, the PLC was assessed in various ways, ranging from use of booklets to a complete set of diagnostic imaging. Inter-rater and intra-rater kappa values ranged from 0.188 to 0.915 and 0.455 to 0.840, respectively. In nine accuracy studies, magnetic resonance (MR) imaging was most often (n = 6) compared with intra-operative findings. In general, MR imaging tended to demonstrate relatively high negative predictive values and relatively low positive predictive values for PLC injuries.

CONCLUSIONS

A wide variety of methods have been applied in the evaluation of precision and accuracy of PLC injury detection, leaving spinal surgeons with a multitude of variable results. There is scant clinical evidence demonstrating the true prognostic value of detected PLC injuries in patients with thoracic and lumbar spine injuries. We recommend the conduct of longitudinal clinical follow-up studies on those cases assessed for precision and/or accuracy of PLC injuries.

Squash(ed): Craniofacial and vertebral injury from collision on squash court

Squash is a popular racquet sport not usually associated with severe head or spinal injury. The incidence of squash-related injury ranges from 35.5 to 80.9 per 100,000 players, with the most common sites being the lower-limbs and eyes. We present a case of extensive traumatic craniomaxillofacial and vertebral injury resulting from collision on a squash court, without use of protective gear. The patient sustained fractures of the frontal bone, orbits, maxillae, zygomas, the first and second cervical vertebrae and the spinous process of the seventh cervical vertrebra. This is the first case of squash-related injury with such extensive craniofacial and vertebral involvement. This unique case required multiple surgical procedures as well as an extensive admission to the intensive care unit and highlights the risk of significant craniomaxillofacial trauma in sports not usually associated with such injuries.